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PROFESSOR: [UNINTELLIGIBLE]
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and we will spend the next
couple of weeks grading them.
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But that was pretty fun on
Friday so [UNINTELLIGIBLE].
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00:00:39,440 --> 00:00:43,370
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We've been talking these
past couple of weeks--
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we've been talking the past
couple of weeks about serious
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games, games for education,
games as an art form, as a
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means of expression.
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And we're going to be continuing
some of those
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discussions later on.
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But the whole idea is to sort
of give you, to sort of prep
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you, for a situation where
you're going to make a game
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for a client.
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And for this last assignment,
you're actually going to be
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making a game based on a problem
that Lisa is going to
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be talking about.
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GUEST SPEAKER 1: My name is
Jim [UNINTELLIGIBLE].
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I'm a clinical psychologist.
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I work at--
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I was at Beth Israel, I'm just
starting at Brigham and
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Women's Hospital, one of the
Harvard mafia hospitals.
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And my area is using interactive
media for clinical
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training but especially for
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treatment of clinical problems.
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So we make computer programs
to help treat clinical
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disorders in psychology.
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GUEST SPEAKER 2: It's
my turn to stand up.
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I'm [UNINTELLIGIBLE].
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I'm a psychiatrist at UMass.
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I trained in the same
place like Jim used
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to work, Beth Israel.
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And my focus is primarily
clinical.
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I'm an attending psychiatrist
in a variety of settings,
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inpatient, outpatient.
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And what I brought up to Jim
and then Phillip was a
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practical question that I will
try to present, which is
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helping psychiatry residents
deal with angry, agitated, and
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potentially [UNINTELLIGIBLE]
patients.
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Later this is a significant
and largely unknown issue.
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Certainly the research is
picking up, and we don't quite
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understand the extent
of the problem.
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And but I'll say more.
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I'll save it for our
presentation.
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Thank you for coming here.
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PROFESSOR: So when they
contacted me, there was the
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usual interest in trying to
make some sort of digital
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piece of software to help the
training residents in learning
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how to deal with violence
in mental institutions.
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And immediately the first thing
that I thought, well
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before we jump right into
digital, let's try doing
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something in analog first.
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Let's try prototyping
something first.
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But it also occurred to me that,
in the real world of
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game design, there's actually a
lot more jobs in game design
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outside of the game industry
than inside the game industry.
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There are a lot of companies out
there that are basically
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looking for solutions.
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Some of which may be games.
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And you might end up working in
some of those capacities.
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A lot of folks in advertising
for instance
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are involved in games.
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A lot of folks who are
interested in improving
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teaching methods, or improving
simulations, working on--
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trying to think of
an example--
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public awareness.
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And people who are also now
working in website design and
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in various online services, who
are trying to think about
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how to make their experiences
a little bit more game like.
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There are really really good
ways of doing that, and there
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are really really bad
ways of doing that.
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And for the most part what we're
hoping is that, if you
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end up getting one of those
jobs, you're going to be able
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to bring some of your personal
insight as having actually
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done game design, as opposed
to just copying what games
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have done, and just assuming,
well, it kind of looks like a
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game, therefore it is a game.
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You guys know that now.
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So this is kind of get your
feet wet, in terms of
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designing something, designing
for somebody else's needs.
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The important thing to keep in
mind is, who is going to be
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playing your game, or who's
this game intended for.
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And in what context are they
going to be playing your game.
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One of the particular problems
that you're trying to address,
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what's the part of
the system that
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you're trying to simulate.
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And what kinds of insights do
you hope people are going to
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get out of that.
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The problem they're going
to talk about it huge.
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If you noticed I uploaded
actually four readings to the
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class website.
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Only one of them is required,
but all of them are useful.
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I will be uploading more.
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These are all reference material
for the team to use
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however you wish.
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Because the problem is so huge
and vast, you don't have to
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solve the whole problem.
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You pick one thing that you're
excited about, that you're
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interested about, and that you
think that you might have a
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good strategy.
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Do the usual brainstorm.
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We're going to be going through
brainstorming and team
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selection pretty much
just this week.
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And try to identify some small
part that might be addressable
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with a card game or a board
game, or I'll talk a little
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bit about role-playing games
in a couple of weeks.
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So with that being said
I'm going to turn
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it over to you guys.
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GUEST SPEAKER 2: OK so we'll
try to take turns to talk
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about violence in psychiatry,
in particular.
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So as Jim has pointed out,
violence is a large issue.
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What I'm going to try to focus
on, as I mentioned earlier,
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rather than engaging with
psychiatric patients,
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especially psychiatric patients
on an inpatient
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program, which is where the
question for me came from.
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And obviously violence
can be looked at in
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a variety of ways.
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And I think in one of the
handouts that I sent to
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Philip, Violence in Mental
Illness, they talk about the
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biological, psychological
theories that the social
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dimension of violence and how
it can be understood.
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If you look at the human
development, and no matter
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what theory you consider,
either a traditional
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drive-based theory like Freud
or Erikson's stages, each
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seems to define a certain
developmental goal, and often,
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achieving or achieving in a
faulty way that goal can
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create potential for aggression
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and sometimes violence.
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A little child or an adult who's
dependent or needs are
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frustrated may try to takeover
and get those met, in one way
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or another.
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So what I use as a
[UNINTELLIGIBLE] metaphor for
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the origins of violence is a
communication breakdown.
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At some level, something doesn't
happen right between
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the person who gets angry and
those around him or her.
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So in a most generic way,
basically communication is
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less about who says what to
whom, than in what channel,
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and with what affect.
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The breakdown can occur
at many levels.
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Again, this is the
generic form.
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I hope I'll [UNINTELLIGIBLE]
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what I mean.
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And especially what can be done
at a practical level,
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let's say when you are the
resident on call at night.
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And the staff calls you up and
says so and so is getting out
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of control.
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She's raising her voice,
threatening, pounding walls,
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wanting to get out, refusing
medications.
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How do you approach
such a person?
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And again, the intervention
can happen
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at different levels.
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And actually one goal of the
training, or potentially the
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game that you might consider,
is what to do.
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How do you establish when do you
engage fully, by yourself,
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with outside help, when
intervention is minimal and
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you just bring pens with you,
restrain the patient, use
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pharmacology.
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So it's a continuum
of interventions.
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I'm going to just focus on
what to do when you can
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actually engage the patient.
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Again, continuing the metaphor
is what Walter Fisher has
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described as this type of
narrative, rationality, as
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opposed to the traditional
rational paradigm that defines
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people as thinking beings that
actually do make decisions and
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base their actions on evidential
reasoning.
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Or rational people.
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We analyze the situation.
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We come up with the best
possible outcome.
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Walter Fisher talks about that
fact that we are all
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storytellers, that we try to
interact and understand others
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based on the narrative
that we have about
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ourselves and about others.
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My assumption, and again, this
is just the introductory
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metaphor if you want, that at
some point violence can be
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caused by a disruption
in this narrative.
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00:10:14,830 --> 00:10:16,330
Things don't make
sense anymore.
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We feel misunderstood.
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We feel the victim
of an injustice.
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And that those principles
apply to somebody who is
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struggling with a
mental illness.
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Where things have a much
narrower window of opportunity
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than for people who are able
to flexibly adapt to the
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demands of reality.
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00:10:35,523 --> 00:10:37,590
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So we all know who this is, and
the reason I put it up--
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and I have to admit I haven't
looked into the copyright, I
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00:10:48,606 --> 00:10:52,610
know there are longer and longer
copyright rules for
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00:10:52,610 --> 00:10:56,440
using cartoons, so you'll
have to forgive me.
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00:10:56,440 --> 00:10:59,820
My point is that this
is an angry person.
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And as someone who
is communicating.
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00:11:02,840 --> 00:11:07,540
I think we get quickly and
clearly the fact that his
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00:11:07,540 --> 00:11:09,744
emotional range may be intense,
207
00:11:09,744 --> 00:11:10,648
but it's fairly narrow.
208
00:11:10,648 --> 00:11:15,200
It doesn't cover like
a spectrum.
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00:11:15,200 --> 00:11:17,560
And the communication
is fairly simple.
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00:11:17,560 --> 00:11:18,670
He's in distress.
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00:11:18,670 --> 00:11:23,080
He is imposing his point
of view, his space.
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00:11:23,080 --> 00:11:28,843
He could become very aggressive
and assaultive.
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00:11:28,843 --> 00:11:31,880
I think that the language
is very simplistic.
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00:11:31,880 --> 00:11:35,010
How would we approach the Hulk
in trying to calm him down and
215
00:11:35,010 --> 00:11:36,756
change his color?
216
00:11:36,756 --> 00:11:40,172
That's the end of my
introductory metaphor.
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00:11:40,172 --> 00:11:43,588
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00:11:43,588 --> 00:11:47,492
And please, feel free to
interrupt, jump in, and make
219
00:11:47,492 --> 00:11:53,860
this presentation as long or
as short as you want me to.
220
00:11:53,860 --> 00:11:57,430
There are many slides, but I'm
not going to go through every
221
00:11:57,430 --> 00:11:58,259
single line.
222
00:11:58,259 --> 00:12:01,241
I'm just using this as a
stimulus for the conversation
223
00:12:01,241 --> 00:12:03,229
especially from your
perspective
224
00:12:03,229 --> 00:12:05,217
and from your needs.
225
00:12:05,217 --> 00:12:08,199
As I said, I'm a clinical
provider, I'm a psychiatrist.
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00:12:08,199 --> 00:12:12,843
I deal with patients all the
time, many of whom are angry
227
00:12:12,843 --> 00:12:15,810
or potentially angry or
potentially assaultive.
228
00:12:15,810 --> 00:12:19,715
And I may do things after so
many years instinctively.
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00:12:19,715 --> 00:12:23,042
But sometimes I have to think
through, OK, this is the
230
00:12:23,042 --> 00:12:26,935
situation, how do I do to
maximize the benefit for the
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00:12:26,935 --> 00:12:29,273
patient I'm treating and
to keep myself safe.
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00:12:29,273 --> 00:12:32,908
I've been assaulted just
once, in 15 years.
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00:12:32,908 --> 00:12:36,150
It was like in the movies.
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00:12:36,150 --> 00:12:41,021
A VA patient, former Green
Beret, who got upset with the
235
00:12:41,021 --> 00:12:46,865
system, and picked up a very
heavy armchair and lifted it
236
00:12:46,865 --> 00:12:48,813
above his head.
237
00:12:48,813 --> 00:12:52,130
And we established
eye contact then.
238
00:12:52,130 --> 00:12:54,770
I think he wondered, what should
I do with this puny
239
00:12:54,770 --> 00:12:55,422
little doctor?
240
00:12:55,422 --> 00:12:58,120
Should I squash him or not?
241
00:12:58,120 --> 00:13:02,530
And at the end, I guess it was a
last, you know, split second
242
00:13:02,530 --> 00:13:05,298
moment, he decided to
throw it to my side.
243
00:13:05,298 --> 00:13:09,561
A large section of the wall came
down, so I was looking at
244
00:13:09,561 --> 00:13:11,780
it wondering, well
I could have been
245
00:13:11,780 --> 00:13:12,766
that wall coming down.
246
00:13:12,766 --> 00:13:13,259
He ran out.
247
00:13:13,259 --> 00:13:15,724
It took him a while--
248
00:13:15,724 --> 00:13:18,190
for people to catch
up with him.
249
00:13:18,190 --> 00:13:21,910
And two cruisers full of police
officers to subdue him.
250
00:13:21,910 --> 00:13:25,540
So I guess, no communication
there.
251
00:13:25,540 --> 00:13:27,440
He was just subdued.
252
00:13:27,440 --> 00:13:29,720
What's the magnitude
of the problem?
253
00:13:29,720 --> 00:13:31,160
I think it's substantial.
254
00:13:31,160 --> 00:13:34,435
And actually more than 10 years
ago, there were some
255
00:13:34,435 --> 00:13:41,079
isolated reports of how
significant the problem was in
256
00:13:41,079 --> 00:13:42,850
terms of the trainees, and
especially psychiatry
257
00:13:42,850 --> 00:13:50,724
trainees, being the target of
verbal and physical violence.
258
00:13:50,724 --> 00:13:54,265
On this first page I
talk about medical
259
00:13:54,265 --> 00:13:56,680
students in one study.
260
00:13:56,680 --> 00:13:58,612
Numbers are relatively small.
261
00:13:58,612 --> 00:14:05,820
But again, the study
is 14 years old.
262
00:14:05,820 --> 00:14:08,790
A survey of psychiatry residents
showed that assaults
263
00:14:08,790 --> 00:14:13,550
or threats of violence are
clearly one of the most
264
00:14:13,550 --> 00:14:15,010
difficult events in
their training.
265
00:14:15,010 --> 00:14:18,226
And some were wondering
introspectively if this is the
266
00:14:18,226 --> 00:14:19,680
right field for them.
267
00:14:19,680 --> 00:14:22,585
Actually some students may
wonder reading this literature
268
00:14:22,585 --> 00:14:24,740
whether psychiatry is
the right field
269
00:14:24,740 --> 00:14:27,620
for them to go into.
270
00:14:27,620 --> 00:14:35,456
And as you see in the fourth
article, almost two-thirds of
271
00:14:35,456 --> 00:14:38,414
psychiatry residents were
assaulted at least once during
272
00:14:38,414 --> 00:14:40,400
their training.
273
00:14:40,400 --> 00:14:44,520
And obviously like with any
dangerous situation, the risk
274
00:14:44,520 --> 00:14:46,925
of post-traumatic symptoms
can be substantial.
275
00:14:46,925 --> 00:14:52,660
Either acute stress response
or longer lasting issues.
276
00:14:52,660 --> 00:14:57,804
The idea of improving their
training and their ability to
277
00:14:57,804 --> 00:15:01,850
deal with the situation
has multiple benefits.
278
00:15:01,850 --> 00:15:04,523
Those who know what
to do are never or
279
00:15:04,523 --> 00:15:05,490
almost never assaulted.
280
00:15:05,490 --> 00:15:09,758
Not only that, if they happened
to be exposed, the
281
00:15:09,758 --> 00:15:12,026
likelihood of developing
post-traumatic goes down
282
00:15:12,026 --> 00:15:12,512
significantly.
283
00:15:12,512 --> 00:15:16,400
So I don't think I need
to demonstrate
284
00:15:16,400 --> 00:15:17,858
that point any further.
285
00:15:17,858 --> 00:15:21,510
The assault rate in a more
[UNINTELLIGIBLE] relatively
286
00:15:21,510 --> 00:15:26,846
recent study, 10 years old,
pretty old, you see that
287
00:15:26,846 --> 00:15:31,520
overall the number of assault
rate was 30% to 40%.
288
00:15:31,520 --> 00:15:34,256
Men tended to be slightly
more physically
289
00:15:34,256 --> 00:15:35,714
assaulted than women.
290
00:15:35,714 --> 00:15:39,602
AUDIENCE: Can you define what
assault means, exactly?
291
00:15:39,602 --> 00:15:41,060
What qualifies as assault?
292
00:15:41,060 --> 00:15:44,766
GUEST SPEAKER 2: Assault
basically means kind of laying
293
00:15:44,766 --> 00:15:46,590
hands on the person.
294
00:15:46,590 --> 00:15:51,680
And the assault resulting in
an injury, of any kind.
295
00:15:51,680 --> 00:15:56,890
Skin being kind of broken
through or--
296
00:15:56,890 --> 00:15:59,245
AUDIENCE: Just holding
the clinician
297
00:15:59,245 --> 00:16:00,335
wouldn't be an assault?
298
00:16:00,335 --> 00:16:02,938
GUEST SPEAKER 2: Well it would
be an assault because that
299
00:16:02,938 --> 00:16:08,090
kind of grabbing action could
actually result in injury.
300
00:16:08,090 --> 00:16:13,614
And I think it would be probably
very limiting to talk
301
00:16:13,614 --> 00:16:15,240
only about physical injuries,
especially since the
302
00:16:15,240 --> 00:16:19,386
psychological consequences are
often the longer lasting and
303
00:16:19,386 --> 00:16:22,230
much more significant.
304
00:16:22,230 --> 00:16:25,230
I think what the surveys have
shown also is that how
305
00:16:25,230 --> 00:16:29,990
unprepared trainees in the
mental health and outside the
306
00:16:29,990 --> 00:16:31,150
mental health field
are actually.
307
00:16:31,150 --> 00:16:34,860
Often this is reduced to a few
lectures, especially during
308
00:16:34,860 --> 00:16:36,150
orientation.
309
00:16:36,150 --> 00:16:40,970
And then they are thrown into
the lion cage and they learn
310
00:16:40,970 --> 00:16:42,790
on the job.
311
00:16:42,790 --> 00:16:47,050
And many of these findings
are introspective.
312
00:16:47,050 --> 00:16:51,220
Many trainees felt that well, I
didn't say anything, because
313
00:16:51,220 --> 00:16:54,310
I thought I was supposed to
toughen up and bite the bullet
314
00:16:54,310 --> 00:16:55,190
and move on.
315
00:16:55,190 --> 00:16:58,240
Or this is part of the job, I
chose this, it's my fault.
316
00:16:58,240 --> 00:17:00,050
Or maybe I did something
wrong.
317
00:17:00,050 --> 00:17:03,580
Maybe I was the one who made
it so the assault happened.
318
00:17:03,580 --> 00:17:09,450
So a lot of reasons that were
just, again, not looked into.
319
00:17:09,450 --> 00:17:10,314
Fear of being scrutinized.
320
00:17:10,314 --> 00:17:12,500
How come that I'm
the one that was
321
00:17:12,500 --> 00:17:16,119
assaulted, and not 10 trainees.
322
00:17:16,119 --> 00:17:17,869
How I'm going to explain this.
323
00:17:17,869 --> 00:17:20,324
I was so frightened that I
cannot even remember clearly
324
00:17:20,324 --> 00:17:20,730
what happened to me.
325
00:17:20,730 --> 00:17:22,670
So there are a variety
of reasons why
326
00:17:22,670 --> 00:17:24,170
people who are in training--
327
00:17:24,170 --> 00:17:28,310
and again, I'm focusing on a
again a very small segment, a
328
00:17:28,310 --> 00:17:31,232
specific group of trainees
in medical
329
00:17:31,232 --> 00:17:32,206
and psychiatric training.
330
00:17:32,206 --> 00:17:35,615
But I could easily think of
other situations of people who
331
00:17:35,615 --> 00:17:38,605
are exposed to the potential
for violence and where such
332
00:17:38,605 --> 00:17:40,880
training would be helpful.
333
00:17:40,880 --> 00:17:46,026
Up until now, and for the most
part the data that I was able
334
00:17:46,026 --> 00:17:48,882
to collect, and most people in
looking at this have been able
335
00:17:48,882 --> 00:17:51,270
to collect is fairly limited.
336
00:17:51,270 --> 00:17:53,890
There are certain limited
number of programs.
337
00:17:53,890 --> 00:17:56,760
Methodologically the research
is quite faulty.
338
00:17:56,760 --> 00:18:03,160
You can just talk about how
limited the generalizability
339
00:18:03,160 --> 00:18:03,965
of the findings are.
340
00:18:03,965 --> 00:18:06,585
And often people have
talked about what
341
00:18:06,585 --> 00:18:07,680
happened in the past.
342
00:18:07,680 --> 00:18:11,772
So clearly the recall bias is
a major limiting factor in
343
00:18:11,772 --> 00:18:15,120
understanding what happened.
344
00:18:15,120 --> 00:18:18,980
Also, as Jim asked me, so how
do you define assault.
345
00:18:18,980 --> 00:18:21,860
One of the biggest problems
with most research in this
346
00:18:21,860 --> 00:18:26,774
field is that defining assault,
aggression, is done
347
00:18:26,774 --> 00:18:29,330
in very idiosyncratic ways.
348
00:18:29,330 --> 00:18:31,955
It's hard to compare
different studies.
349
00:18:31,955 --> 00:18:34,902
350
00:18:34,902 --> 00:18:39,790
So this is a compilation of what
people in different areas
351
00:18:39,790 --> 00:18:42,460
have thought about in
terms of improving
352
00:18:42,460 --> 00:18:43,860
the psychiatric training.
353
00:18:43,860 --> 00:18:49,886
And as you see most often, in
the last few years, the idea
354
00:18:49,886 --> 00:18:56,590
of using simulation to expose
the trainees to a protected
355
00:18:56,590 --> 00:19:00,320
environment that has clearly
defined boundaries and
356
00:19:00,320 --> 00:19:05,297
consequences, and basically that
can be repeated almost in
357
00:19:05,297 --> 00:19:09,225
identical fashion in order to
gain proficiency, this coming
358
00:19:09,225 --> 00:19:12,171
up more and more.
359
00:19:12,171 --> 00:19:16,410
What many training programs
are doing is to use
360
00:19:16,410 --> 00:19:20,076
standardized patients
that use actors.
361
00:19:20,076 --> 00:19:23,338
And that of course
would behave in
362
00:19:23,338 --> 00:19:26,720
a programmed fashion.
363
00:19:26,720 --> 00:19:29,810
They make get up to you and
make fists, but hopefully
364
00:19:29,810 --> 00:19:32,980
they'll not get so much into
the role and then they're
365
00:19:32,980 --> 00:19:33,755
punching you.
366
00:19:33,755 --> 00:19:37,420
GUEST SPEAKER 1: I think this is
the real challenge, is that
367
00:19:37,420 --> 00:19:40,271
there's different levels
of learning.
368
00:19:40,271 --> 00:19:42,320
You can learn kind of a list of
facts, things to do if your
369
00:19:42,320 --> 00:19:44,270
patient starts to get agitated
and threatening.
370
00:19:44,270 --> 00:19:46,970
And you can learn how to take a
test on it and forget it the
371
00:19:46,970 --> 00:19:49,020
next day, especially if
it doesn't come up
372
00:19:49,020 --> 00:19:51,110
for you right away.
373
00:19:51,110 --> 00:19:53,400
And then there's the question
of internalizing it so you
374
00:19:53,400 --> 00:19:56,380
actually have not just kind of a
working knowledge but really
375
00:19:56,380 --> 00:19:58,140
understand what you should
do in different kinds of
376
00:19:58,140 --> 00:19:59,540
circumstances.
377
00:19:59,540 --> 00:20:03,270
And that's where the idea of
role playing with live role
378
00:20:03,270 --> 00:20:04,440
plays for the trainees--
379
00:20:04,440 --> 00:20:06,960
it could be residents, and
mental health providers--
380
00:20:06,960 --> 00:20:10,390
can really be helpful so they
have some sense, some
381
00:20:10,390 --> 00:20:15,120
semblance of this kind
of training.
382
00:20:15,120 --> 00:20:18,180
But the tricky things with these
role plays is it's not
383
00:20:18,180 --> 00:20:23,490
easy to ensure that everybody
receives high quality access
384
00:20:23,490 --> 00:20:25,270
to well trained actors.
385
00:20:25,270 --> 00:20:28,310
Here at Harvard Medical School,
they probably do.
386
00:20:28,310 --> 00:20:29,610
At UMass, they probably do.
387
00:20:29,610 --> 00:20:30,850
But there's a lot of places.
388
00:20:30,850 --> 00:20:33,122
And if you expand beyond
psychiatry to every mental
389
00:20:33,122 --> 00:20:35,560
health center in the country,
every caseworker who is going
390
00:20:35,560 --> 00:20:38,720
out to visit a patient at their
home, or social worker,
391
00:20:38,720 --> 00:20:41,310
they're definitely not getting
this kind of training.
392
00:20:41,310 --> 00:20:45,510
And so the ones who really I
think you said before are
393
00:20:45,510 --> 00:20:46,940
really well trained are
the nurses, actually.
394
00:20:46,940 --> 00:20:49,090
Because they get a different
kind of training that's really
395
00:20:49,090 --> 00:20:50,980
pretty effective,
it sounds like.
396
00:20:50,980 --> 00:20:52,870
But the mental health
care providers
397
00:20:52,870 --> 00:20:53,900
often have no training.
398
00:20:53,900 --> 00:20:55,980
And then they're the ones who
are kind of in a closed room
399
00:20:55,980 --> 00:20:59,040
with the person who can
become really violent.
400
00:20:59,040 --> 00:21:01,665
Especially if it's at their
home, or an inpatient unit.
401
00:21:01,665 --> 00:21:03,750
GUEST SPEAKER 2: Jim was making
reference to that
402
00:21:03,750 --> 00:21:07,000
psychiatrist at MGH who last
year was stabbed by a patient
403
00:21:07,000 --> 00:21:08,650
in the outpatient clinic.
404
00:21:08,650 --> 00:21:10,475
GUEST SPEAKER 1: You all hear
about this last year?
405
00:21:10,475 --> 00:21:12,295
Can you just describe
the situation?
406
00:21:12,295 --> 00:21:14,826
GUEST SPEAKER 2: Well, it was
late in the evening, when most
407
00:21:14,826 --> 00:21:17,230
things like this have the
potential of happening.
408
00:21:17,230 --> 00:21:22,620
This was a neuro evaluation
or [UNINTELLIGIBLE]
409
00:21:22,620 --> 00:21:25,490
in the Bipolar Clinic at MGH.
410
00:21:25,490 --> 00:21:31,333
Basically he was angry from the
beginning and was able to
411
00:21:31,333 --> 00:21:32,800
stab repeatedly.
412
00:21:32,800 --> 00:21:36,280
An off guard person who just
happened to walk by.
413
00:21:36,280 --> 00:21:37,720
GUEST SPEAKER 1: It was a
police officer, right?
414
00:21:37,720 --> 00:21:38,290
GUEST SPEAKER 2: Yeah.
415
00:21:38,290 --> 00:21:41,360
He was one of the security
people for
416
00:21:41,360 --> 00:21:42,360
that particular clinic.
417
00:21:42,360 --> 00:21:44,340
He came and he had a gun.
418
00:21:44,340 --> 00:21:47,830
I don't know how often off-duty
security people carry
419
00:21:47,830 --> 00:21:49,240
their guns.
420
00:21:49,240 --> 00:21:52,130
But he opened and killed
the patient.
421
00:21:52,130 --> 00:21:55,724
So he was charged.
422
00:21:55,724 --> 00:21:58,210
Eventually was cleared.
423
00:21:58,210 --> 00:21:59,690
For using excessive force.
424
00:21:59,690 --> 00:22:01,020
GUEST SPEAKER 1: What happened
to the psychiatrist?
425
00:22:01,020 --> 00:22:03,686
GUEST SPEAKER 2: Well, the
psychiatrist was admitted into
426
00:22:03,686 --> 00:22:07,074
the hospital and required
extensive surgeries.
427
00:22:07,074 --> 00:22:10,946
She was stabbed in the chest
and in the neck.
428
00:22:10,946 --> 00:22:14,095
It was a fairly gruesome-- she
survived and I think she's
429
00:22:14,095 --> 00:22:14,940
back at work.
430
00:22:14,940 --> 00:22:16,980
But this is an extreme case.
431
00:22:16,980 --> 00:22:21,450
And I'm afraid that many of the
things that we talk about,
432
00:22:21,450 --> 00:22:23,800
the principles that we may
come up with, may not
433
00:22:23,800 --> 00:22:28,620
necessarily be so helpful, other
than thinking back at a
434
00:22:28,620 --> 00:22:29,445
level of intervention.
435
00:22:29,445 --> 00:22:33,230
It is quite conceivable that
for somebody who charges at
436
00:22:33,230 --> 00:22:36,066
you, you won't be able to talk
him down, you won't be able to
437
00:22:36,066 --> 00:22:40,682
use any of the nice
de-escalation principles that
438
00:22:40,682 --> 00:22:42,480
I'm going to talk about
in a few minutes.
439
00:22:42,480 --> 00:22:45,290
But, figuring out what
do, I think it means
440
00:22:45,290 --> 00:22:45,982
[UNINTELLIGIBLE].
441
00:22:45,982 --> 00:22:50,690
AUDIENCE: You mentioned that
nurses have a different
442
00:22:50,690 --> 00:22:53,720
training system for this, and
it seems to be effective.
443
00:22:53,720 --> 00:22:56,630
444
00:22:56,630 --> 00:22:59,150
What is that training, like what
is different about what
445
00:22:59,150 --> 00:23:00,386
nurses get taught?
446
00:23:00,386 --> 00:23:05,420
GUEST SPEAKER 2: Well, there
are some, in most states,
447
00:23:05,420 --> 00:23:11,484
there are some regulations that
try to implement some
448
00:23:11,484 --> 00:23:14,412
level of training or are
designed specifically for
449
00:23:14,412 --> 00:23:17,600
patients who get
out of control.
450
00:23:17,600 --> 00:23:19,430
And that's not only
psychiatry.
451
00:23:19,430 --> 00:23:25,595
Emergency room teams have
probably the most highest rate
452
00:23:25,595 --> 00:23:29,640
of assaultive patients, across
diagnostic departments.
453
00:23:29,640 --> 00:23:32,278
Often psychiatric patients,
especially patients using
454
00:23:32,278 --> 00:23:35,530
substance abuse, will
get out of control.
455
00:23:35,530 --> 00:23:39,690
So if you want to become an
emergency physician, or if you
456
00:23:39,690 --> 00:23:42,649
work in the field as an EMT or
another capacity, you'll have
457
00:23:42,649 --> 00:23:44,400
to deal with these situations.
458
00:23:44,400 --> 00:23:50,460
What makes the nurses somewhat
better trained is that they
459
00:23:50,460 --> 00:23:54,032
often are the frontline
staff dealing with
460
00:23:54,032 --> 00:23:55,180
out of control patients.
461
00:23:55,180 --> 00:23:57,478
And I think that's probably
pretty sad, because physicians
462
00:23:57,478 --> 00:24:01,350
should be equally, and trainees,
physicians and
463
00:24:01,350 --> 00:24:04,254
trainees should be equally
well trained.
464
00:24:04,254 --> 00:24:08,580
But on the nursing front, there
has been some progress.
465
00:24:08,580 --> 00:24:11,170
In Massachusetts, the Department
of Mental Health
466
00:24:11,170 --> 00:24:13,250
has some mandatory training.
467
00:24:13,250 --> 00:24:17,590
But there's a lot of red tape
there, but there a lot of
468
00:24:17,590 --> 00:24:20,455
helpful aspects, including
aspects
469
00:24:20,455 --> 00:24:23,412
related to stop attacks.
470
00:24:23,412 --> 00:24:28,410
And I wish I could have
presented a recording of a
471
00:24:28,410 --> 00:24:31,270
training session for staff.
472
00:24:31,270 --> 00:24:35,230
When I went to it, I thought it
would be something like a
473
00:24:35,230 --> 00:24:37,593
very spectacular kind of
kung-fu, how you do it.
474
00:24:37,593 --> 00:24:41,510
When in fact, the emphasis is
how to keep yourself safe, and
475
00:24:41,510 --> 00:24:44,410
believe it or not how to keep
the person safe, the person
476
00:24:44,410 --> 00:24:49,620
that you're blocking the
punches, the person that may
477
00:24:49,620 --> 00:24:55,040
be trying to strangle you, or
keep you in a stronghold, or
478
00:24:55,040 --> 00:24:57,750
scratch you, or rip your hair.
479
00:24:57,750 --> 00:25:00,170
Again, even when you're trying
to be intervene or you're
480
00:25:00,170 --> 00:25:03,109
trying to protect yourself,
and keep the
481
00:25:03,109 --> 00:25:04,558
other person safe.
482
00:25:04,558 --> 00:25:10,360
No punching, kicking, no kind
of spectacular steps.
483
00:25:10,360 --> 00:25:15,816
But again, that's also I feel
could be an interesting topic
484
00:25:15,816 --> 00:25:17,812
for a simulation.
485
00:25:17,812 --> 00:25:20,806
How do you interact with--
486
00:25:20,806 --> 00:25:24,299
especially since again
I'm a totally kind of
487
00:25:24,299 --> 00:25:26,810
outsider in the field.
488
00:25:26,810 --> 00:25:31,020
Having kids, they were asking
me the other day about
489
00:25:31,020 --> 00:25:32,270
Microsoft's Kinect.
490
00:25:32,270 --> 00:25:34,190
491
00:25:34,190 --> 00:25:37,985
And I thought that was really
interesting because the level
492
00:25:37,985 --> 00:25:43,890
of interaction with computer
generated interfaces is very
493
00:25:43,890 --> 00:25:47,335
interesting, and certainly
would be a safe bet to be
494
00:25:47,335 --> 00:25:50,245
attacked by somebody
from the TV.
495
00:25:50,245 --> 00:25:54,530
AUDIENCE: It sounds like the
nurses get better training
496
00:25:54,530 --> 00:25:58,840
because the states require them
to have better training.
497
00:25:58,840 --> 00:25:59,760
GUEST SPEAKER 2:
That's correct.
498
00:25:59,760 --> 00:26:00,680
That's a part of it.
499
00:26:00,680 --> 00:26:04,950
I've been trying at UMass to
suggest that not only the
500
00:26:04,950 --> 00:26:09,930
staff physicians get exposed to
the training but even the
501
00:26:09,930 --> 00:26:12,110
psychiatry trainees and other
trainees, especially in
502
00:26:12,110 --> 00:26:13,270
emergency medicine.
503
00:26:13,270 --> 00:26:16,204
They should all really
know about it.
504
00:26:16,204 --> 00:26:18,921
GUEST SPEAKER 1: I suspect some
of this have to do with
505
00:26:18,921 --> 00:26:20,156
the benefits of being
in a union.
506
00:26:20,156 --> 00:26:23,614
So a union can demand that
nurses receive this better
507
00:26:23,614 --> 00:26:26,084
training, where the physicians
don't have a union.
508
00:26:26,084 --> 00:26:28,090
GUEST SPEAKER 2: It's
also about numbers.
509
00:26:28,090 --> 00:26:31,720
On any unit, you
have six, seven
510
00:26:31,720 --> 00:26:33,420
nurses for one physician.
511
00:26:33,420 --> 00:26:36,400
And the nurses are there in
shifts around the clock.
512
00:26:36,400 --> 00:26:39,686
So their likelihood of being
exposed to an out-of-control
513
00:26:39,686 --> 00:26:42,320
patient are much higher.
514
00:26:42,320 --> 00:26:46,380
Usually on these units people
intervene as a team.
515
00:26:46,380 --> 00:26:51,796
And as a team leader that tries
to apply so many of the
516
00:26:51,796 --> 00:26:52,800
principles I'm going
to talk about.
517
00:26:52,800 --> 00:26:57,216
And then if there is need for
seclusion or restraints, then
518
00:26:57,216 --> 00:27:00,330
that has to be done in a
coordinated fashion.
519
00:27:00,330 --> 00:27:02,894
And things are much clearer,
as I said,
520
00:27:02,894 --> 00:27:04,630
on the nursing front.
521
00:27:04,630 --> 00:27:06,340
Maybe because they are doing
it all the time and because
522
00:27:06,340 --> 00:27:08,498
there are some tight
regulations,
523
00:27:08,498 --> 00:27:11,942
because they're unionized.
524
00:27:11,942 --> 00:27:16,472
And at least half of the
literature really comes from
525
00:27:16,472 --> 00:27:17,650
the nursing direction.
526
00:27:17,650 --> 00:27:23,050
So that's a tangent.
527
00:27:23,050 --> 00:27:27,215
PROFESSOR: Just want to ride
off the Kinect comment that
528
00:27:27,215 --> 00:27:28,065
you were making.
529
00:27:28,065 --> 00:27:30,125
We will be talking about a
little bit more about live
530
00:27:30,125 --> 00:27:33,790
action games so that's kind of
how you prototype something
531
00:27:33,790 --> 00:27:37,156
that's going to be a motion
gesture computer game.
532
00:27:37,156 --> 00:27:38,320
You don't obfuscate.
533
00:27:38,320 --> 00:27:42,434
Actually having to write code to
do that, that sort of body
534
00:27:42,434 --> 00:27:45,843
recognition, is kind of annoying
and expensive.
535
00:27:45,843 --> 00:27:50,226
But you can test off a lot of
ideas just by having two
536
00:27:50,226 --> 00:27:51,690
people play with coding.
537
00:27:51,690 --> 00:27:54,500
Safety becomes the biggest
concern for
538
00:27:54,500 --> 00:27:55,530
the players as well.
539
00:27:55,530 --> 00:27:58,659
It's kind of interesting in this
particular case that you
540
00:27:58,659 --> 00:28:00,887
are trying to teach someone
how to prevent
541
00:28:00,887 --> 00:28:04,440
damage to both parties.
542
00:28:04,440 --> 00:28:06,030
That actually kind of
helps you with the
543
00:28:06,030 --> 00:28:09,050
design a lot actually.
544
00:28:09,050 --> 00:28:12,145
That's only one problem.
545
00:28:12,145 --> 00:28:16,065
You'll go into more details
about the kinds of things to
546
00:28:16,065 --> 00:28:19,516
prevent it escalating into
actual conflict.
547
00:28:19,516 --> 00:28:24,446
GUEST SPEAKER 2: And the idea
is basically to do your best
548
00:28:24,446 --> 00:28:27,897
to not end up at that particular
extreme of direct
549
00:28:27,897 --> 00:28:31,850
combat, which is not--
550
00:28:31,850 --> 00:28:33,520
So ideally you don't
have to go there.
551
00:28:33,520 --> 00:28:36,580
And as I said in 15 years I've
been assaulted once.
552
00:28:36,580 --> 00:28:38,340
I'm sure I was lucky.
553
00:28:38,340 --> 00:28:43,750
People think that my eyebrows
are intimidating.
554
00:28:43,750 --> 00:28:50,198
So don't tend to get very
[UNINTELLIGIBLE].
555
00:28:50,198 --> 00:28:53,500
Again I'm going to tell a few,
you know, tell you about a few
556
00:28:53,500 --> 00:28:55,470
pearls and a few tricks
that I personally use.
557
00:28:55,470 --> 00:29:00,010
It may not be helpful
for everybody.
558
00:29:00,010 --> 00:29:02,070
Over time, you develop
you own style.
559
00:29:02,070 --> 00:29:08,168
The idea is to be able to make
an assessment and try to take
560
00:29:08,168 --> 00:29:09,136
preventative steps.
561
00:29:09,136 --> 00:29:10,588
And I think that's the secret.
562
00:29:10,588 --> 00:29:14,460
And this is what I hope better
training may be the user
563
00:29:14,460 --> 00:29:16,396
simulation and gaming
would be helpful.
564
00:29:16,396 --> 00:29:19,300
565
00:29:19,300 --> 00:29:25,010
Now I'm going to just, I'm going
to jump into talking
566
00:29:25,010 --> 00:29:29,195
about prevention and
[UNINTELLIGIBLE]
567
00:29:29,195 --> 00:29:32,930
but identifying how you assess
and how you think about the
568
00:29:32,930 --> 00:29:34,380
potential for violence.
569
00:29:34,380 --> 00:29:41,282
And these are some known risk
factors for aggression.
570
00:29:41,282 --> 00:29:45,154
Obviously the history of
violence is the top.
571
00:29:45,154 --> 00:29:51,132
How recent, how frequently,
those people become
572
00:29:51,132 --> 00:29:52,750
assaultive.
573
00:29:52,750 --> 00:29:55,210
What's the pattern
of escalation.
574
00:29:55,210 --> 00:29:56,260
What are the associated
symptoms.
575
00:29:56,260 --> 00:30:00,480
What happens before somebody
becomes assaultive.
576
00:30:00,480 --> 00:30:02,030
Why is this important?
577
00:30:02,030 --> 00:30:05,999
Because you can do, and probably
should do before, you
578
00:30:05,999 --> 00:30:09,410
engage with the patient an
assessment at that level.
579
00:30:09,410 --> 00:30:13,170
And it will help you figure out
how deep to get involved,
580
00:30:13,170 --> 00:30:15,050
how likely you are to
[UNINTELLIGIBLE] the patient.
581
00:30:15,050 --> 00:30:19,206
Versus saying, oh, I don't need
this, I need help, let's
582
00:30:19,206 --> 00:30:20,454
go in as a team.
583
00:30:20,454 --> 00:30:23,850
So that-- that makes
it important.
584
00:30:23,850 --> 00:30:25,830
People often talk about
violence and a rise in
585
00:30:25,830 --> 00:30:26,630
tendencies.
586
00:30:26,630 --> 00:30:28,920
Young people tend to
be more assaultive,
587
00:30:28,920 --> 00:30:30,710
and there's no surprise.
588
00:30:30,710 --> 00:30:36,590
Also older people who have
dementia and get more
589
00:30:36,590 --> 00:30:40,991
disinhibited and more likely
to become reactive.
590
00:30:40,991 --> 00:30:43,191
I always like to tell
the story about a
591
00:30:43,191 --> 00:30:43,925
patient with dementia.
592
00:30:43,925 --> 00:30:47,125
I was moonlighting, and he swung
at me as I was passing.
593
00:30:47,125 --> 00:30:49,065
And then I went to
talk to him.
594
00:30:49,065 --> 00:30:52,680
Well, I don't know, you just
passed by, and I was upset,
595
00:30:52,680 --> 00:30:53,800
and you were the closest.
596
00:30:53,800 --> 00:30:56,790
So I thought I would try to--
597
00:30:56,790 --> 00:31:01,320
So there was no way for
me to predict that.
598
00:31:01,320 --> 00:31:05,336
It wasn't a serious thing, it
wasn't a predatory type of
599
00:31:05,336 --> 00:31:07,292
assaultiveness where
somebody plans.
600
00:31:07,292 --> 00:31:10,715
Doesn't like you,
goes after you.
601
00:31:10,715 --> 00:31:15,116
A colleague of mine was
attacked by a patient.
602
00:31:15,116 --> 00:31:19,517
The patient watched when people
were not around, went
603
00:31:19,517 --> 00:31:22,290
into the doctors room,
locked the
604
00:31:22,290 --> 00:31:24,160
door, and started punching.
605
00:31:24,160 --> 00:31:26,684
So that's a totally
different animal.
606
00:31:26,684 --> 00:31:29,521
So the distinction between
impulsive, affective if you
607
00:31:29,521 --> 00:31:36,710
want or the type of aggression
and the predatory is essential
608
00:31:36,710 --> 00:31:39,640
to keep in mind.
609
00:31:39,640 --> 00:31:48,080
In some subcultures, violence is
not allowed certainly much
610
00:31:48,080 --> 00:31:49,020
more frequent.
611
00:31:49,020 --> 00:31:53,322
People of a lower socioeconomic
status may be
612
00:31:53,322 --> 00:31:56,160
more likely to become
assaultive.
613
00:31:56,160 --> 00:31:59,035
Patients of a limited cognitive
ability, especially
614
00:31:59,035 --> 00:32:02,899
when institutionalized, are
way more likely to become
615
00:32:02,899 --> 00:32:03,382
assaultive.
616
00:32:03,382 --> 00:32:07,725
And then it's many, many
diagnoses increase the
617
00:32:07,725 --> 00:32:09,705
likelihood of assaultiveness.
618
00:32:09,705 --> 00:32:13,170
The top are psychotic disorders,
like schizophrenia.
619
00:32:13,170 --> 00:32:18,120
Mood disorders like bipolar.
620
00:32:18,120 --> 00:32:22,390
I told you about what we call
cognitive disorders,
621
00:32:22,390 --> 00:32:26,460
especially dementia and
confusional states.
622
00:32:26,460 --> 00:32:30,080
Patients that have had traumatic
brain injuries or
623
00:32:30,080 --> 00:32:32,966
that have had epilepsy.
624
00:32:32,966 --> 00:32:35,852
GUEST SPEAKER 1: There's a
real problem with Iraq or
625
00:32:35,852 --> 00:32:39,410
Afghanistan veterans, when they
have had an IE explode
626
00:32:39,410 --> 00:32:40,540
under their vehicle.
627
00:32:40,540 --> 00:32:42,660
And they had a brain injury.
628
00:32:42,660 --> 00:32:44,750
Now they have a lot of
disinhibition about violence.
629
00:32:44,750 --> 00:32:48,745
And they can just go off
sometimes very unexpectedly.
630
00:32:48,745 --> 00:32:51,730
GUEST SPEAKER 2: The frontal
lobe exerts a sort of
631
00:32:51,730 --> 00:32:57,370
inhibitory influence on our
ability to function.
632
00:32:57,370 --> 00:33:00,350
And that allows us
to plan, to think
633
00:33:00,350 --> 00:33:03,200
ahead, to sequence events.
634
00:33:03,200 --> 00:33:07,000
This is the executive function
of our frontal lobe.
635
00:33:07,000 --> 00:33:11,864
When it's impaired either in a
trauma, or after surgery, or
636
00:33:11,864 --> 00:33:16,256
being in an accident, or
becoming demented, that
637
00:33:16,256 --> 00:33:22,112
ability to operate in that
fashion may be impaired.
638
00:33:22,112 --> 00:33:25,040
Violence is a possible
side effect.
639
00:33:25,040 --> 00:33:28,330
Substance abuse are at the top
of the list, because of the
640
00:33:28,330 --> 00:33:33,412
disinhibition, both during the
intoxication phase and during
641
00:33:33,412 --> 00:33:36,085
the withdrawal people tend to
become very agitated and
642
00:33:36,085 --> 00:33:37,800
assaultive.
643
00:33:37,800 --> 00:33:41,668
There are certain personality
disorders.
644
00:33:41,668 --> 00:33:46,840
So when we think about the
percentage order, we have this
645
00:33:46,840 --> 00:33:51,315
enduring maladaptive patterns
of relating to you and to
646
00:33:51,315 --> 00:33:53,428
others and to the world.
647
00:33:53,428 --> 00:33:56,886
The obsessive compulsive
personality disorder likes to
648
00:33:56,886 --> 00:33:58,862
have things organized,
planned.
649
00:33:58,862 --> 00:34:01,002
Nothing-- even going
on vacation is
650
00:34:01,002 --> 00:34:01,826
an exhausting task.
651
00:34:01,826 --> 00:34:05,165
Nothing has to happen
randomly.
652
00:34:05,165 --> 00:34:09,690
The grandiose personalities
really need this kind of
653
00:34:09,690 --> 00:34:12,550
feeling coming from
all directions.
654
00:34:12,550 --> 00:34:15,210
They need to be in
the limelight.
655
00:34:15,210 --> 00:34:19,370
They use people, not as real
people but as people that
656
00:34:19,370 --> 00:34:23,320
provide sustenance to their
own self esteem.
657
00:34:23,320 --> 00:34:27,844
Two type of personality
disorders are particularly
658
00:34:27,844 --> 00:34:31,630
likely to promote violence.
659
00:34:31,630 --> 00:34:37,340
The antisocial and you may have
heard the term borderline
660
00:34:37,340 --> 00:34:40,723
personality disorder, which
is basically at core has
661
00:34:40,723 --> 00:34:43,675
significant instability and
emotions and interpersonal
662
00:34:43,675 --> 00:34:49,579
relationships and identity
and basically
663
00:34:49,579 --> 00:34:51,750
their lives are a mess.
664
00:34:51,750 --> 00:34:55,260
Often they feel abandoned,
they feel put down.
665
00:34:55,260 --> 00:34:59,504
They may get briefly paranoid
and often they become
666
00:34:59,504 --> 00:35:00,390
assaultive.
667
00:35:00,390 --> 00:35:04,360
So again, I'm throwing
a lot of terms and
668
00:35:04,360 --> 00:35:05,320
definitions at you.
669
00:35:05,320 --> 00:35:10,803
I don't want to make this a
lecture about psychiatry.
670
00:35:10,803 --> 00:35:14,033
But these are conditions
that I think are
671
00:35:14,033 --> 00:35:15,276
helpful to think about.
672
00:35:15,276 --> 00:35:19,252
AUDIENCE: When people with
delusional disorders like
673
00:35:19,252 --> 00:35:22,731
schizophrenia get violent, is
it usually because they are
674
00:35:22,731 --> 00:35:24,719
frustrated about something or
is it because they suddenly
675
00:35:24,719 --> 00:35:27,701
have some sort of delusion about
their clinician that
676
00:35:27,701 --> 00:35:30,925
involves requiring them to take
some sort of action that
677
00:35:30,925 --> 00:35:31,875
is violent?
678
00:35:31,875 --> 00:35:33,150
GUEST SPEAKER 2: I think both.
679
00:35:33,150 --> 00:35:37,086
I think even people that have a
psychotic disorder have the
680
00:35:37,086 --> 00:35:40,040
right to feel the victim
of an injustice or
681
00:35:40,040 --> 00:35:41,650
feel frustrated or--
682
00:35:41,650 --> 00:35:44,437
many of the reasons that I
talked about could happen.
683
00:35:44,437 --> 00:35:49,427
But in particular,
I think the other
684
00:35:49,427 --> 00:35:50,425
point is equally important.
685
00:35:50,425 --> 00:35:52,920
That they may act on a
delusional conviction.
686
00:35:52,920 --> 00:35:59,820
Or their psychosis may also
have hallucinations.
687
00:35:59,820 --> 00:36:04,733
And command auditory
hallucinations are known to
688
00:36:04,733 --> 00:36:07,840
often be the forerunners
of a violent attack.
689
00:36:07,840 --> 00:36:10,720
You talk about me
and say things.
690
00:36:10,720 --> 00:36:14,810
Or the voice tells me, I'm
going to go after you.
691
00:36:14,810 --> 00:36:21,310
And the person feels hopeless
to resist that.
692
00:36:21,310 --> 00:36:24,210
I discharged a patient,
was doing great.
693
00:36:24,210 --> 00:36:25,870
Next day he comes back.
694
00:36:25,870 --> 00:36:30,060
Went home, the voice told him
that he needs to hurt his
695
00:36:30,060 --> 00:36:33,490
mother, otherwise he'll
get disemboweled.
696
00:36:33,490 --> 00:36:37,360
So he started punching her and
then chased her with a knife.
697
00:36:37,360 --> 00:36:42,137
She had to hide in a neighbor's
house until the
698
00:36:42,137 --> 00:36:43,530
police arrived.
699
00:36:43,530 --> 00:36:47,836
There is an interesting threat
control override here that
700
00:36:47,836 --> 00:36:52,130
people who have looked at
violence have prescribed as
701
00:36:52,130 --> 00:36:56,340
being sometimes the proximal
cause for violence.
702
00:36:56,340 --> 00:36:59,423
People feel directly
threatened.
703
00:36:59,423 --> 00:37:05,345
And they also have this
overpowering urge that they
704
00:37:05,345 --> 00:37:08,110
need to act on that they
cannot resist.
705
00:37:08,110 --> 00:37:09,450
It's a controversial concept.
706
00:37:09,450 --> 00:37:12,190
I'm not so sure why we should
give this particular
707
00:37:12,190 --> 00:37:16,492
association a higher status
than other delusional
708
00:37:16,492 --> 00:37:20,420
convictions about the neighbors
watching me or
709
00:37:20,420 --> 00:37:23,240
planning to kill me, or putting
together a variety of
710
00:37:23,240 --> 00:37:28,330
clues that my friends are really
trying to get rid of me
711
00:37:28,330 --> 00:37:29,530
and then I need to
protect myself.
712
00:37:29,530 --> 00:37:31,230
But you are absolutely right.
713
00:37:31,230 --> 00:37:34,890
What's interesting even though
patients with 20 psychiatric
714
00:37:34,890 --> 00:37:38,680
disorders may have their reasons
to become assaultive,
715
00:37:38,680 --> 00:37:41,780
in the overall bigger scheme
of things, when you look at
716
00:37:41,780 --> 00:37:46,240
actual violent assaults
committed in society, they're
717
00:37:46,240 --> 00:37:48,270
responsible for a tiny one.
718
00:37:48,270 --> 00:37:52,343
So it's an interesting way
of looking at numbers.
719
00:37:52,343 --> 00:37:57,170
Yes they could become violent,
but the reality is that their
720
00:37:57,170 --> 00:38:00,130
numbers, the actual violent
acts, are very small.
721
00:38:00,130 --> 00:38:04,906
But anyway this may just be a
kind of statistical trick.
722
00:38:04,906 --> 00:38:07,997
AUDIENCE: You're talking about
the number of cases of violent
723
00:38:07,997 --> 00:38:11,495
episodes compared to the
general population.
724
00:38:11,495 --> 00:38:12,120
GUEST SPEAKER 2: Exactly.
725
00:38:12,120 --> 00:38:15,600
That's exactly the problem
right there.
726
00:38:15,600 --> 00:38:19,505
And then there are various
acute findings when you
727
00:38:19,505 --> 00:38:20,960
examine the patient.
728
00:38:20,960 --> 00:38:23,870
On what we call the mental
status examination.
729
00:38:23,870 --> 00:38:26,295
Obviously, hostilities,
suspiciousness, agitation are
730
00:38:26,295 --> 00:38:28,235
all associated with violence.
731
00:38:28,235 --> 00:38:35,220
732
00:38:35,220 --> 00:38:38,630
I want us to focus one minute
on the so-called aggressive
733
00:38:38,630 --> 00:38:48,527
attributional style, how do we
respond to stress when we have
734
00:38:48,527 --> 00:38:51,960
a perception of threat.
735
00:38:51,960 --> 00:38:57,927
This is the threat override
delusion that I mentioned.
736
00:38:57,927 --> 00:38:59,899
I think that's quite relevant.
737
00:38:59,899 --> 00:39:02,860
738
00:39:02,860 --> 00:39:06,690
What happens in conditions of
uncertainty, and many of these
739
00:39:06,690 --> 00:39:10,930
patients may have to think
in a distorted fashion.
740
00:39:10,930 --> 00:39:16,690
I was talking at the
beginning about the
741
00:39:16,690 --> 00:39:19,380
communication breakdown.
742
00:39:19,380 --> 00:39:22,132
You have the layer of the mental
illness that shrinks
743
00:39:22,132 --> 00:39:22,910
your options.
744
00:39:22,910 --> 00:39:25,640
You have a particular situation
to deal with that
745
00:39:25,640 --> 00:39:30,850
makes you even more likely
to become assaulted.
746
00:39:30,850 --> 00:39:34,215
And this constellation of
cognitive distortions may make
747
00:39:34,215 --> 00:39:37,400
it more likely for you
to become assaulted.
748
00:39:37,400 --> 00:39:40,400
Neglecting the base information,
which assigns a
749
00:39:40,400 --> 00:39:45,960
high weight to certain events
that otherwise are low
750
00:39:45,960 --> 00:39:52,360
frequency, attending only to
facts that would confirm your
751
00:39:52,360 --> 00:39:55,510
assumptions, I think--
752
00:39:55,510 --> 00:39:59,040
AUDIENCE: So if the
psychiatrist's office calls to
753
00:39:59,040 --> 00:40:02,350
reschedule an appointment, the
person assumes that this is
754
00:40:02,350 --> 00:40:04,820
because the psychiatrist
doesn't like him.
755
00:40:04,820 --> 00:40:07,850
This person doesn't want to
treat me, they don't like me,
756
00:40:07,850 --> 00:40:09,350
they don't want me to be their
patient because they
757
00:40:09,350 --> 00:40:10,785
rescheduled me.
758
00:40:10,785 --> 00:40:13,720
GUEST SPEAKER 2: Ignoring facts
that could disconfirm
759
00:40:13,720 --> 00:40:16,440
your hypothesis.
760
00:40:16,440 --> 00:40:19,649
I just talked to the
psychiatrist who was nice to
761
00:40:19,649 --> 00:40:23,450
me, but still the fact that he
called and canceled is the
762
00:40:23,450 --> 00:40:26,530
overriding explanation that
he doesn't like me.
763
00:40:26,530 --> 00:40:30,875
Or focusing on common events
just because you remember
764
00:40:30,875 --> 00:40:33,920
them, which is an interesting
way of explaining.
765
00:40:33,920 --> 00:40:36,050
The fact that you remember
them and it brings
766
00:40:36,050 --> 00:40:38,135
them up in the rack.
767
00:40:38,135 --> 00:40:40,510
And other disconfirming
evidence is
768
00:40:40,510 --> 00:40:42,885
totally kind of ignored.
769
00:40:42,885 --> 00:40:45,270
AUDIENCE: In spite the
assumption that the train on
770
00:40:45,270 --> 00:40:47,420
the other platform always
seems to arrive first.
771
00:40:47,420 --> 00:40:50,354
Because those are the
ones you remember.
772
00:40:50,354 --> 00:40:52,310
GUEST SPEAKER 2: Or the
garden variety, the
773
00:40:52,310 --> 00:40:55,740
grass is always greener.
774
00:40:55,740 --> 00:40:59,450
And I talked about medications
and street drugs.
775
00:40:59,450 --> 00:41:01,220
Some are more likely
to be associated.
776
00:41:01,220 --> 00:41:03,300
Alcohol just by the
sheer volume.
777
00:41:03,300 --> 00:41:06,800
And especially because
withdrawal is so violent.
778
00:41:06,800 --> 00:41:08,335
It's a significant issue.
779
00:41:08,335 --> 00:41:12,530
The intoxication phase, your
level of coordination, your
780
00:41:12,530 --> 00:41:17,110
perception of facts, it's just
they're so off that you are
781
00:41:17,110 --> 00:41:19,156
more likely to lose control.
782
00:41:19,156 --> 00:41:24,336
Antidepressants have an
interesting impact, because in
783
00:41:24,336 --> 00:41:27,136
people that have an underlying
tendency to swing in their
784
00:41:27,136 --> 00:41:29,100
moods may actually all
[? blend those ?] things.
785
00:41:29,100 --> 00:41:34,460
You may have heard of the news
of antidepressants promoting
786
00:41:34,460 --> 00:41:37,700
violence and suicide
in adolescents.
787
00:41:37,700 --> 00:41:40,320
And while statisticians are
still scratching their heads
788
00:41:40,320 --> 00:41:44,260
to figure out the exact numbers,
the truth is that
789
00:41:44,260 --> 00:41:48,183
mood is very unstable
in adolescents.
790
00:41:48,183 --> 00:41:51,350
And often initial depression
may turn out to
791
00:41:51,350 --> 00:41:52,670
be something else.
792
00:41:52,670 --> 00:41:55,310
You give somebody an
antidepressant, call him or
793
00:41:55,310 --> 00:41:57,240
her for followup in six
or eight months.
794
00:41:57,240 --> 00:41:59,480
In the meanwhile, lots of
things could happen.
795
00:41:59,480 --> 00:42:02,484
And I think in those cases,
when actually those young
796
00:42:02,484 --> 00:42:07,600
adolescents committed suicide,
it was not so much about
797
00:42:07,600 --> 00:42:09,010
antidepressants causing it.
798
00:42:09,010 --> 00:42:11,595
Probably the antidepressants
made the symptoms worse.
799
00:42:11,595 --> 00:42:14,270
It was very poor followup
and poor diagnostic.
800
00:42:14,270 --> 00:42:18,950
But anyway, this is getting
too technical.
801
00:42:18,950 --> 00:42:20,400
I included this last minute.
802
00:42:20,400 --> 00:42:26,530
This is an interesting summary
of a nationwide study focusing
803
00:42:26,530 --> 00:42:30,900
on violence risk assessment.
804
00:42:30,900 --> 00:42:37,454
Let me just take two minutes
about useful measures in
805
00:42:37,454 --> 00:42:39,440
assessing dynamic
to the violence.
806
00:42:39,440 --> 00:42:43,130
People have looked at violence
in two ways.
807
00:42:43,130 --> 00:42:45,990
They have put together
all those factors
808
00:42:45,990 --> 00:42:47,530
that I presented initially.
809
00:42:47,530 --> 00:42:53,053
And they have looked at the
perspective of those who have
810
00:42:53,053 --> 00:42:53,210
become violent.
811
00:42:53,210 --> 00:42:56,040
And they compiled the
history, clinical
812
00:42:56,040 --> 00:42:58,130
risk assessment scale.
813
00:42:58,130 --> 00:43:00,430
The problem is that when you're
dealing with somebody,
814
00:43:00,430 --> 00:43:03,530
those scales, even though they
may give you a good image of
815
00:43:03,530 --> 00:43:06,950
what happens in the long run,
they may not help you deal
816
00:43:06,950 --> 00:43:08,490
with the immediate situation.
817
00:43:08,490 --> 00:43:12,910
So clinical scales have been
used in [UNINTELLIGIBLE].
818
00:43:12,910 --> 00:43:16,210
One developed in Norway, the
other one, the dynamic
819
00:43:16,210 --> 00:43:17,860
appraisal, developed
in Australia.
820
00:43:17,860 --> 00:43:21,325
These are the items
for the HCR-20.
821
00:43:21,325 --> 00:43:25,550
And it's almost like a
repetition of what I said
822
00:43:25,550 --> 00:43:26,570
earlier in terms of
risk factors.
823
00:43:26,570 --> 00:43:28,750
This is the historical
risk factors.
824
00:43:28,750 --> 00:43:30,780
And these are validated, because
they have been used
825
00:43:30,780 --> 00:43:33,410
for more than 15 years.
826
00:43:33,410 --> 00:43:38,540
The clinical scale is the
dynamic part of the HCR.
827
00:43:38,540 --> 00:43:41,480
And then the risk management
scale is trying to project in
828
00:43:41,480 --> 00:43:45,710
the future what you have to do
in order to ensure safety,
829
00:43:45,710 --> 00:43:47,400
what could go wrong.
830
00:43:47,400 --> 00:43:49,850
GUEST SPEAKER 1: So the value
of these scales is kind of
831
00:43:49,850 --> 00:43:54,490
sizing up the likelihood of this
person coming violent, in
832
00:43:54,490 --> 00:43:55,790
the absence of other
information.
833
00:43:55,790 --> 00:43:58,280
The best predictor is probably
what they're actually doing
834
00:43:58,280 --> 00:44:00,200
behaviorally in front of you.
835
00:44:00,200 --> 00:44:05,220
They're reaching for something
heavy, I take that in and
836
00:44:05,220 --> 00:44:07,510
weigh that heavily.
837
00:44:07,510 --> 00:44:09,580
But in the absence of anything
else, you know that the people
838
00:44:09,580 --> 00:44:15,365
who meet a certain profile are
more likely to be violent as a
839
00:44:15,365 --> 00:44:16,960
psychiatric patient
than others.
840
00:44:16,960 --> 00:44:19,477
GUEST SPEAKER 2: This is a
dynamic scale that looks at
841
00:44:19,477 --> 00:44:22,960
what happens in front of you,
as you pointed out.
842
00:44:22,960 --> 00:44:25,950
You're considering confusion
or debility, how boisterous
843
00:44:25,950 --> 00:44:28,960
and how verbally threatening
the person is.
844
00:44:28,960 --> 00:44:32,360
The most recent one is the
dynamic appraisal of the
845
00:44:32,360 --> 00:44:36,030
situation aggression that has
seven factors that seems to be
846
00:44:36,030 --> 00:44:38,330
the best one [UNINTELLIGIBLE]
847
00:44:38,330 --> 00:44:40,120
assessment or prediction
of violence
848
00:44:40,120 --> 00:44:43,950
over the next 24 hours.
849
00:44:43,950 --> 00:44:50,028
And this is an interesting
psychopathy and an index.
850
00:44:50,028 --> 00:44:53,300
Psychopathy has an interesting
history.
851
00:44:53,300 --> 00:44:58,700
I think the current version
that we all talk about is
852
00:44:58,700 --> 00:45:00,090
antisocial personality.
853
00:45:00,090 --> 00:45:04,860
But basically refers to people
with minimal capacity for
854
00:45:04,860 --> 00:45:08,840
empathy, whose moral dimensions
is fairly
855
00:45:08,840 --> 00:45:13,985
primitive, who engage in
stealing, cheating, violence,
856
00:45:13,985 --> 00:45:19,320
and don't have a lot of moral
drawbacks to do it.
857
00:45:19,320 --> 00:45:22,686
It seems to be associated with
violence, not surprisingly.
858
00:45:22,686 --> 00:45:27,700
And this is actually a factor
analysis that identifies those
859
00:45:27,700 --> 00:45:30,860
two dimensions.
860
00:45:30,860 --> 00:45:36,560
Now just at the end I want to
talk about the de-escalation
861
00:45:36,560 --> 00:45:42,370
principles that I am actually
now trying to incorporate in
862
00:45:42,370 --> 00:45:48,500
the standardized patients,
because these should be fairly
863
00:45:48,500 --> 00:45:54,060
easy to at least present, and
then maybe hopefully to teach
864
00:45:54,060 --> 00:45:56,892
the residents how to use
in terms of dealing
865
00:45:56,892 --> 00:45:57,850
with agitated patients.
866
00:45:57,850 --> 00:46:04,654
So actually many of them
are used by staff.
867
00:46:04,654 --> 00:46:09,630
How to start interaction
with a violent patient.
868
00:46:09,630 --> 00:46:11,690
How to position yourself.
869
00:46:11,690 --> 00:46:14,560
Within arm's length.
870
00:46:14,560 --> 00:46:17,930
Probably at 45 degrees.
871
00:46:17,930 --> 00:46:20,170
For two reasons.
872
00:46:20,170 --> 00:46:25,250
One, in case you're attacked,
to offer a much smaller
873
00:46:25,250 --> 00:46:28,990
surface of the impact and also
to allow you a way to escape,
874
00:46:28,990 --> 00:46:31,910
you have to.
875
00:46:31,910 --> 00:46:34,170
Not obviously to block
the exit door.
876
00:46:34,170 --> 00:46:37,490
Stand over if the person is
leaning down or in the bed.
877
00:46:37,490 --> 00:46:39,870
Never turn your back.
878
00:46:39,870 --> 00:46:41,750
What to do with you
your hands.
879
00:46:41,750 --> 00:46:44,840
Never make fists, or kind of
keep your arms crossed, or
880
00:46:44,840 --> 00:46:50,840
behind you, or in your pockets,
to kind of appear as
881
00:46:50,840 --> 00:46:52,770
nonthreatening as possible.
882
00:46:52,770 --> 00:46:55,535
How to regulate the
eye contact.
883
00:46:55,535 --> 00:46:58,325
If it's too intense, it
can become bothersome.
884
00:46:58,325 --> 00:47:02,915
If it lacks completely, then
people could conclude that you
885
00:47:02,915 --> 00:47:05,682
are not really interested
or involved.
886
00:47:05,682 --> 00:47:08,490
GUEST SPEAKER 1: The thing
that's important to keep in
887
00:47:08,490 --> 00:47:11,910
mind with a psychiatric
patient is,
888
00:47:11,910 --> 00:47:12,670
well, a couple things.
889
00:47:12,670 --> 00:47:16,930
One is that mental health
patients are much more likely
890
00:47:16,930 --> 00:47:18,670
to be the victims
of violence than
891
00:47:18,670 --> 00:47:19,370
actually to commit violence.
892
00:47:19,370 --> 00:47:22,490
And this is really the outlier,
the unusual case
893
00:47:22,490 --> 00:47:25,340
where the psychiatric patient
becomes violent.
894
00:47:25,340 --> 00:47:27,240
But obviously it's an
important situation.
895
00:47:27,240 --> 00:47:30,090
It does happen frequently enough
to be a real concern
896
00:47:30,090 --> 00:47:32,364
for the providers, for
their well being.
897
00:47:32,364 --> 00:47:39,810
898
00:47:39,810 --> 00:47:41,980
Basically there's different
levels of what you have to
899
00:47:41,980 --> 00:47:43,150
understand how to do.
900
00:47:43,150 --> 00:47:46,135
One, how to protect yourself,
and then two, how to protect
901
00:47:46,135 --> 00:47:46,410
the patient.
902
00:47:46,410 --> 00:47:50,752
It's almost like if your child
who's 11 years old comes at
903
00:47:50,752 --> 00:47:53,440
you swinging, it's really
different than if you're
904
00:47:53,440 --> 00:47:54,710
getting bumped on the subway
in terms of what
905
00:47:54,710 --> 00:47:56,060
you're going to do.
906
00:47:56,060 --> 00:47:58,370
Now the person who's sitting in
your office might be a lot
907
00:47:58,370 --> 00:47:59,160
bigger than your 11 year old.
908
00:47:59,160 --> 00:48:00,240
But you kind of get the idea.
909
00:48:00,240 --> 00:48:04,982
You're not trying to punish
them, you're not trying to
910
00:48:04,982 --> 00:48:08,790
inflict any more harm on them
than is absolutely needed in
911
00:48:08,790 --> 00:48:11,306
order to stop the situation
and for you to get
912
00:48:11,306 --> 00:48:13,176
out, or let them out.
913
00:48:13,176 --> 00:48:13,940
GUEST SPEAKER 2: Yes.
914
00:48:13,940 --> 00:48:15,480
And that's important,
and that's somewhat
915
00:48:15,480 --> 00:48:16,730
counter-intuitive.
916
00:48:16,730 --> 00:48:20,450
917
00:48:20,450 --> 00:48:22,906
I'm just thinking, I'm trying to
think in terms of potential
918
00:48:22,906 --> 00:48:28,870
simulation, and targets for
our training paradigm.
919
00:48:28,870 --> 00:48:33,874
I think an important aspect is
for the person who is going to
920
00:48:33,874 --> 00:48:36,075
the training to understand
himself or herself.
921
00:48:36,075 --> 00:48:38,779
How what's the reaction when
you are threatened.
922
00:48:38,779 --> 00:48:41,500
And how to continue to
think on your feet.
923
00:48:41,500 --> 00:48:44,920
And take decisions that are not
based on a flight or fight
924
00:48:44,920 --> 00:48:48,880
or tend and befriend attitude.
925
00:48:48,880 --> 00:48:52,840
This is not about dealing
with a common situation.
926
00:48:52,840 --> 00:48:55,810
This is when you have to
maintain your ability to
927
00:48:55,810 --> 00:48:58,955
remain therapeutic and helpful
and to minimize harm to
928
00:48:58,955 --> 00:49:02,470
yourself and certainly harm
to the other person.
929
00:49:02,470 --> 00:49:04,900
And the truth of the matter is
that many people in these
930
00:49:04,900 --> 00:49:11,340
situations react the way that
they've always done.
931
00:49:11,340 --> 00:49:15,540
I gave Jim the example of a
social worker I work with, who
932
00:49:15,540 --> 00:49:19,660
every time when she is
confronted by a patient, she
933
00:49:19,660 --> 00:49:24,633
gets angry and she gets
defensive and tells things to
934
00:49:24,633 --> 00:49:26,820
her that I find are hurtful.
935
00:49:26,820 --> 00:49:29,710
And they are just adding
gas to the fire.
936
00:49:29,710 --> 00:49:31,640
I need to intervene because
you feel that it's almost
937
00:49:31,640 --> 00:49:33,850
like, you know, I'm
there to umpire.
938
00:49:33,850 --> 00:49:35,010
OK, time out.
939
00:49:35,010 --> 00:49:35,440
Stop.
940
00:49:35,440 --> 00:49:38,296
We need to do something else.
941
00:49:38,296 --> 00:49:40,686
And I try to explain to her.
942
00:49:40,686 --> 00:49:42,450
She just doesn't get it.
943
00:49:42,450 --> 00:49:47,968
Or can theoretically figure
it out but doesn't do a
944
00:49:47,968 --> 00:49:49,270
very good job at it.
945
00:49:49,270 --> 00:49:53,515
When we are angry or frightened,
our behavior, the
946
00:49:53,515 --> 00:49:57,100
way we talk, the way
we track, changes.
947
00:49:57,100 --> 00:50:00,544
And those things can be major
triggers for the other person.
948
00:50:00,544 --> 00:50:03,780
GUEST SPEAKER 1: If you're
staying really calm, and the
949
00:50:03,780 --> 00:50:06,975
other person's escalating,
that's a real dampening force
950
00:50:06,975 --> 00:50:09,780
on that other person from
escalating even more.
951
00:50:09,780 --> 00:50:13,396
And it's really, really hard to
do, to stay professional.
952
00:50:13,396 --> 00:50:16,475
And recognizing that
this aggression is
953
00:50:16,475 --> 00:50:17,910
really a medical symptom.
954
00:50:17,910 --> 00:50:20,986
It's like if they are bleeding
on the floor.
955
00:50:20,986 --> 00:50:23,070
The difference obviously is that
it could actually hurt
956
00:50:23,070 --> 00:50:24,220
you, the provider.
957
00:50:24,220 --> 00:50:26,435
But you need to recognize it
as a medical symptom that
958
00:50:26,435 --> 00:50:28,820
needs to be dealt with as
opposed to taking it really
959
00:50:28,820 --> 00:50:34,287
personally, or you being
violent back.
960
00:50:34,287 --> 00:50:35,810
GUEST SPEAKER 2: How
do you appear.
961
00:50:35,810 --> 00:50:38,210
How do you--
962
00:50:38,210 --> 00:50:41,038
obviously, being calm, centered,
self assured is
963
00:50:41,038 --> 00:50:41,986
always helpful.
964
00:50:41,986 --> 00:50:45,320
It's the message that
you're conveying.
965
00:50:45,320 --> 00:50:50,460
Often if you respond to anger
by being fearful or angry
966
00:50:50,460 --> 00:50:55,505
yourself, obviously these
will just escalate.
967
00:50:55,505 --> 00:50:58,970
Or if you're fidgety and
pacing, and gesturing
968
00:50:58,970 --> 00:51:03,302
yourself, and wondering, so what
do I do now, I think the
969
00:51:03,302 --> 00:51:07,510
other person would clearly
pick up that feeling.
970
00:51:07,510 --> 00:51:12,924
Touching most often than
not is not a good idea.
971
00:51:12,924 --> 00:51:15,369
Even though instinctively we
would like to calm the other
972
00:51:15,369 --> 00:51:17,325
person down or wonder
what it is.
973
00:51:17,325 --> 00:51:21,230
This is how we learn to show
empathy and that we care, we
974
00:51:21,230 --> 00:51:21,730
want to help.
975
00:51:21,730 --> 00:51:27,510
Well, it may not
be a good idea.
976
00:51:27,510 --> 00:51:33,273
And then this could be
a topic in itself.
977
00:51:33,273 --> 00:51:36,710
Active listening would
be the most--
978
00:51:36,710 --> 00:51:40,147
if you want the buzzword,
in terms of the verbal
979
00:51:40,147 --> 00:51:42,130
de-escalation principle.
980
00:51:42,130 --> 00:51:46,650
Often when I'm called, and
many of my colleagues are
981
00:51:46,650 --> 00:51:48,210
called in such situations.
982
00:51:48,210 --> 00:51:49,670
I introduce myself.
983
00:51:49,670 --> 00:51:53,246
I'm telling the person no
matter how agitated
984
00:51:53,246 --> 00:51:55,745
he is why I'm here.
985
00:51:55,745 --> 00:51:58,400
And I'm trying to understand.
986
00:51:58,400 --> 00:52:02,260
I may not respond or react
to the person's curses or
987
00:52:02,260 --> 00:52:03,200
threatening behavior.
988
00:52:03,200 --> 00:52:05,490
Of course I try to maintain
a safe distance.
989
00:52:05,490 --> 00:52:07,815
And I continue my assessment.
990
00:52:07,815 --> 00:52:11,305
Can I deal with this, or I need
help, or I need to stop
991
00:52:11,305 --> 00:52:13,916
and find another way.
992
00:52:13,916 --> 00:52:19,800
And I give that person feedback
about what I see, how
993
00:52:19,800 --> 00:52:21,628
he or she makes me feel.
994
00:52:21,628 --> 00:52:24,400
I feel you are threatening, I
feel uncomfortable, I think we
995
00:52:24,400 --> 00:52:24,910
need to stop.
996
00:52:24,910 --> 00:52:26,400
Do you want to talk?
997
00:52:26,400 --> 00:52:30,580
What are the issues that
you're dealing with?
998
00:52:30,580 --> 00:52:37,214
And I also explain and set
limits on what is acceptable
999
00:52:37,214 --> 00:52:39,120
and what is not acceptable.
1000
00:52:39,120 --> 00:52:41,706
Often, that combination works.
1001
00:52:41,706 --> 00:52:44,910
1002
00:52:44,910 --> 00:52:48,340
I listed pharmacotherapy and
seclusion restraint because
1003
00:52:48,340 --> 00:52:51,280
they are part of the process,
and I think I would like
1004
00:52:51,280 --> 00:52:56,670
people who are trained for this
to understand that those
1005
00:52:56,670 --> 00:52:57,920
things are available.
1006
00:52:57,920 --> 00:53:04,290
1007
00:53:04,290 --> 00:53:05,757
Any questions so far?
1008
00:53:05,757 --> 00:53:11,625
1009
00:53:11,625 --> 00:53:15,048
AUDIENCE: I've just got a
couple of comments on
1010
00:53:15,048 --> 00:53:16,026
[UNINTELLIGIBLE].
1011
00:53:16,026 --> 00:53:16,612
GUEST SPEAKER 1: Yeah.
1012
00:53:16,612 --> 00:53:17,004
We can do that.
1013
00:53:17,004 --> 00:53:18,960
And also I wanted to suggest and
see what you think about
1014
00:53:18,960 --> 00:53:22,924
this, if someone would like to
play the role of a patient, I
1015
00:53:22,924 --> 00:53:25,575
can meet with you briefly and
just kind of prepare you to do
1016
00:53:25,575 --> 00:53:28,170
that if anybody is interested
in taking the role of the
1017
00:53:28,170 --> 00:53:28,685
aggressive patient.
1018
00:53:28,685 --> 00:53:30,445
You'd like to do that?
1019
00:53:30,445 --> 00:53:33,910
Why don't you and I step out for
just a couple of minutes.
1020
00:53:33,910 --> 00:53:36,385
And then [UNINTELLIGIBLE]?
1021
00:53:36,385 --> 00:53:37,635
[INTERPOSING VOICES]
1022
00:53:37,635 --> 00:53:42,820
1023
00:53:42,820 --> 00:53:47,710
PROFESSOR: So there's a couple
of things that have been
1024
00:53:47,710 --> 00:53:50,780
brought up already, immediately
seem to be
1025
00:53:50,780 --> 00:53:54,830
possible places where you guys
can think of what you're doing
1026
00:53:54,830 --> 00:53:57,070
to do your project on.
1027
00:53:57,070 --> 00:54:00,690
There's identifying factors.
1028
00:54:00,690 --> 00:54:04,850
There's a whole bunch of
different schemes and
1029
00:54:04,850 --> 00:54:08,700
different metrics that people
have been using.
1030
00:54:08,700 --> 00:54:13,410
All the way from known
personality types to
1031
00:54:13,410 --> 00:54:16,790
socioeconomic factors and
personal history.
1032
00:54:16,790 --> 00:54:20,400
You could make some kind
of [UNINTELLIGIBLE].
1033
00:54:20,400 --> 00:54:23,500
I can imagine, some sort of like
can you figure out enough
1034
00:54:23,500 --> 00:54:27,290
information before
it's too late.
1035
00:54:27,290 --> 00:54:30,266
The dynamic assessment of
violence seems to be more of a
1036
00:54:30,266 --> 00:54:32,050
time pressure kind of thing.
1037
00:54:32,050 --> 00:54:34,870
Because you almost have to
figure out on the spot.
1038
00:54:34,870 --> 00:54:37,690
But factors are very
different.
1039
00:54:37,690 --> 00:54:41,730
But similarly I can find
de-escalation.
1040
00:54:41,730 --> 00:54:44,750
1041
00:54:44,750 --> 00:54:47,270
It seems kind of interesting,
because it almost seems like
1042
00:54:47,270 --> 00:54:48,840
you could make a word game.
1043
00:54:48,840 --> 00:54:54,052
Or a face to face kind
of thing out of that.
1044
00:54:54,052 --> 00:54:59,645
Can you remember what you're
supposed to do in conversation
1045
00:54:59,645 --> 00:55:03,110
with each other without
missing any of the
1046
00:55:03,110 --> 00:55:04,100
[UNINTELLIGIBLE].
1047
00:55:04,100 --> 00:55:06,080
And that might be something.
1048
00:55:06,080 --> 00:55:07,980
That would be like a live
action game but not
1049
00:55:07,980 --> 00:55:09,808
necessarily a physical game.
1050
00:55:09,808 --> 00:55:12,550
It would be more like
a party game.
1051
00:55:12,550 --> 00:55:16,160
GUEST SPEAKER 2: One way--
1052
00:55:16,160 --> 00:55:18,295
this is, by the way, I didn't
want to go there to
1053
00:55:18,295 --> 00:55:19,080
make this too long.
1054
00:55:19,080 --> 00:55:23,650
But these are some parts of a
standardized patient that I'm
1055
00:55:23,650 --> 00:55:27,340
putting together, then I'm going
to try actually to talk
1056
00:55:27,340 --> 00:55:30,538
to the simulation department
at UMass, to be
1057
00:55:30,538 --> 00:55:32,014
played by an actor.
1058
00:55:32,014 --> 00:55:37,060
And this would be the
training goals.
1059
00:55:37,060 --> 00:55:40,465
And I'm really particularly
interested in how people
1060
00:55:40,465 --> 00:55:43,316
respond when they are exposed to
an angry situation or even
1061
00:55:43,316 --> 00:55:44,910
to an angry face.
1062
00:55:44,910 --> 00:55:46,442
What do you have to
do in order to
1063
00:55:46,442 --> 00:55:47,750
de-escalate the patient.
1064
00:55:47,750 --> 00:55:55,620
And what I think I'm going to
suggest to the actor is that,
1065
00:55:55,620 --> 00:55:58,130
you are in the room and you're
pacing up and down.
1066
00:55:58,130 --> 00:55:59,100
And appearing angry.
1067
00:55:59,100 --> 00:56:03,170
And you're allowed to use some
generic swear words.
1068
00:56:03,170 --> 00:56:06,170
And to have a number
of complaints.
1069
00:56:06,170 --> 00:56:07,936
Could be a number of them.
1070
00:56:07,936 --> 00:56:10,150
Nurse was too late to give
me the medications.
1071
00:56:10,150 --> 00:56:13,140
The girlfriend didn't
come in time.
1072
00:56:13,140 --> 00:56:14,530
You owe money.
1073
00:56:14,530 --> 00:56:17,509
You just had a job interview
today and you missed it
1074
00:56:17,509 --> 00:56:18,540
because you're in
the hospital.
1075
00:56:18,540 --> 00:56:19,930
Could be a number of things.
1076
00:56:19,930 --> 00:56:22,050
And then the person
approaches you.
1077
00:56:22,050 --> 00:56:24,660
1078
00:56:24,660 --> 00:56:30,400
The trainee should follow some
rules in terms of the verbal
1079
00:56:30,400 --> 00:56:32,040
and nonverbal de-escalation.
1080
00:56:32,040 --> 00:56:37,270
If that person is able to engage
you, you can become
1081
00:56:37,270 --> 00:56:41,890
less angry, less agitated,
more interested.
1082
00:56:41,890 --> 00:56:45,910
Pacing less, lower your voice.
1083
00:56:45,910 --> 00:56:49,970
If the trainee is just doing the
right or wrong things, you
1084
00:56:49,970 --> 00:56:53,460
either stay at the same level
or get more and more angry.
1085
00:56:53,460 --> 00:56:57,440
Of course, it's fairly demanding
for a standardized
1086
00:56:57,440 --> 00:57:01,990
for an actor, because the
nonverbal elements are easy.
1087
00:57:01,990 --> 00:57:03,250
How you regulate the distance.
1088
00:57:03,250 --> 00:57:05,595
How you look, how
you approach.
1089
00:57:05,595 --> 00:57:10,055
You inhibit your natural
tendencies to pat the person
1090
00:57:10,055 --> 00:57:11,370
on the shoulder, whatever.
1091
00:57:11,370 --> 00:57:14,180
But the verbal aspects
are more difficult.
1092
00:57:14,180 --> 00:57:15,410
AUDIENCE: Improvising dialog
on the spot is hard.
1093
00:57:15,410 --> 00:57:16,615
GUEST SPEAKER 2: Exactly.
1094
00:57:16,615 --> 00:57:21,290
But at the same time, the goals
of the dialog are not.
1095
00:57:21,290 --> 00:57:25,410
Because you should probably find
out what's going on, even
1096
00:57:25,410 --> 00:57:28,820
though, let's say, the actor
will try to tell you about his
1097
00:57:28,820 --> 00:57:30,550
life, and how miserable
things are.
1098
00:57:30,550 --> 00:57:34,200
You know, I lost my job,
and I was kicked out.
1099
00:57:34,200 --> 00:57:36,850
But you need to try to
bring the person
1100
00:57:36,850 --> 00:57:37,400
to what really happened.
1101
00:57:37,400 --> 00:57:41,820
I think that's very, very
helpful because you're pinning
1102
00:57:41,820 --> 00:57:46,630
down a particular conflict
that triggered it.
1103
00:57:46,630 --> 00:57:48,680
And if you are able to
do that, then you
1104
00:57:48,680 --> 00:57:50,340
can take some steps.
1105
00:57:50,340 --> 00:57:50,980
OK.
1106
00:57:50,980 --> 00:57:53,980
I have a patient right
now who has
1107
00:57:53,980 --> 00:57:55,970
difficulty expressing herself.
1108
00:57:55,970 --> 00:58:01,045
And systematically there's one
particular shift where the
1109
00:58:01,045 --> 00:58:04,010
staff is not patient, doesn't
wait for her.
1110
00:58:04,010 --> 00:58:06,670
You just need to give her
a little bit more time.
1111
00:58:06,670 --> 00:58:09,300
And she gets upset and angry
and starts pacing.
1112
00:58:09,300 --> 00:58:12,105
And I have to every time say,
please, listen to her.
1113
00:58:12,105 --> 00:58:15,225
Or she comes up to me, she tells
me the story and then I
1114
00:58:15,225 --> 00:58:17,070
have to go back to the staff.
1115
00:58:17,070 --> 00:58:20,900
People just don't have the
patience or don't care.
1116
00:58:20,900 --> 00:58:22,600
So that's just a simple
intervention.
1117
00:58:22,600 --> 00:58:25,660
This is why you need to find
out what's going on.
1118
00:58:25,660 --> 00:58:28,480
And then, if you can get more
information about what brought
1119
00:58:28,480 --> 00:58:32,724
the person to this place.
1120
00:58:32,724 --> 00:58:33,690
GUEST SPEAKER 1: OK.
1121
00:58:33,690 --> 00:58:36,600
I think we're prepared.
1122
00:58:36,600 --> 00:58:39,790
She did role play before
I showed this, because
1123
00:58:39,790 --> 00:58:41,350
[UNINTELLIGIBLE].
1124
00:58:41,350 --> 00:58:42,530
GUEST SPEAKER 2: Do
you want to do it?
1125
00:58:42,530 --> 00:58:43,060
You've been trained.
1126
00:58:43,060 --> 00:58:43,850
GUEST SPEAKER 1: No.
1127
00:58:43,850 --> 00:58:45,940
You're the expert actually.
1128
00:58:45,940 --> 00:58:47,937
GUEST SPEAKER 2: OK.
1129
00:58:47,937 --> 00:58:48,931
Alright.
1130
00:58:48,931 --> 00:58:51,416
Let's see what happens to me.
1131
00:58:51,416 --> 00:58:56,890
[AUDIENCE LAUGHTER]
1132
00:58:56,890 --> 00:59:00,765
So, I'm Dr. [? See. ?]
1133
00:59:00,765 --> 00:59:01,980
ROLE PLAYING PATIENT:
Where's John?
1134
00:59:01,980 --> 00:59:03,772
I want to speak to John.
1135
00:59:03,772 --> 00:59:07,070
I respond to him
and I want him.
1136
00:59:07,070 --> 00:59:08,610
Why isn't he here?
1137
00:59:08,610 --> 00:59:09,200
Why?
1138
00:59:09,200 --> 00:59:11,140
GUEST SPEAKER 2: Who's
this person?
1139
00:59:11,140 --> 00:59:12,110
I don't know.
1140
00:59:12,110 --> 00:59:13,565
ROLE PLAYING PATIENT:
Where's John?
1141
00:59:13,565 --> 00:59:15,020
I only want to speak to him.
1142
00:59:15,020 --> 00:59:17,384
GUEST SPEAKER 2: Well, Nurse
John is not available.
1143
00:59:17,384 --> 00:59:18,328
ROLE PLAYING PATIENT:
[BANGING NOISE]
1144
00:59:18,328 --> 00:59:19,744
Why isn't he available?
1145
00:59:19,744 --> 00:59:21,640
Why?
1146
00:59:21,640 --> 00:59:23,212
Only [UNINTELLIGIBLE].
1147
00:59:23,212 --> 00:59:25,642
I don't want to talk
to you right now.
1148
00:59:25,642 --> 00:59:27,586
GUEST SPEAKER 2: How
can I help you?
1149
00:59:27,586 --> 00:59:28,558
ROLE PLAYING PATIENT:
Get Johnny.
1150
00:59:28,558 --> 00:59:29,530
GUEST SPEAKER 2: OK.
1151
00:59:29,530 --> 00:59:31,474
I can try to see
if he's around.
1152
00:59:31,474 --> 00:59:32,446
ROLE PLAYING PATIENT:
[BANGING NOISE]
1153
00:59:32,446 --> 00:59:34,390
You could [UNINTELLIGIBLE]
now.
1154
00:59:34,390 --> 00:59:35,860
GUEST SPEAKER 2: OK.
1155
00:59:35,860 --> 00:59:37,822
But what else can I do?
1156
00:59:37,822 --> 00:59:38,786
ROLE PLAYING PATIENT: Um.
1157
00:59:38,786 --> 00:59:41,678
An education.
1158
00:59:41,678 --> 00:59:42,642
Stop it.
1159
00:59:42,642 --> 00:59:43,606
Not good.
1160
00:59:43,606 --> 00:59:45,550
Try to poison me.
1161
00:59:45,550 --> 00:59:46,460
You all want me dead.
1162
00:59:46,460 --> 00:59:48,742
GUEST SPEAKER 2: What am
I trying to do to you?
1163
00:59:48,742 --> 00:59:51,097
ROLE PLAYING PATIENT: Doesn't
[UNINTELLIGIBLE].
1164
00:59:51,097 --> 00:59:52,039
GUEST SPEAKER 2: OK.
1165
00:59:52,039 --> 00:59:54,865
I can talk about that.
1166
00:59:54,865 --> 00:59:57,526
So tell me what kind of problems
do you have with the
1167
00:59:57,526 --> 00:59:58,004
medication?
1168
00:59:58,004 --> 00:59:59,450
ROLE PLAYING PATIENT:
Trying to poison.
1169
00:59:59,450 --> 01:00:01,822
You all want me dead.
1170
01:00:01,822 --> 01:00:03,206
GUEST SPEAKER 2: So you
don't think the
1171
01:00:03,206 --> 01:00:05,070
medication is helpful?
1172
01:00:05,070 --> 01:00:06,555
ROLE PLAYING PATIENT:
Course not.
1173
01:00:06,555 --> 01:00:09,030
Trying to kill me.
1174
01:00:09,030 --> 01:00:10,020
[TEARING NOISE]
1175
01:00:10,020 --> 01:00:11,505
[LAUGHTER]
1176
01:00:11,505 --> 01:00:13,485
ROLE PLAYING PATIENT:
They're watching me.
1177
01:00:13,485 --> 01:00:17,940
1178
01:00:17,940 --> 01:00:22,395
GUEST SPEAKER 2: What else
can I do to help?
1179
01:00:22,395 --> 01:00:23,880
ROLE PLAYING PATIENT:
[INAUDIBLE]
1180
01:00:23,880 --> 01:00:24,970
family.
1181
01:00:24,970 --> 01:00:27,195
GUEST SPEAKER 2: You want me
to contact your family?
1182
01:00:27,195 --> 01:00:27,940
ROLE PLAYING PATIENT: No.
1183
01:00:27,940 --> 01:00:28,890
I hate them all.
1184
01:00:28,890 --> 01:00:31,340
They're all against me.
1185
01:00:31,340 --> 01:00:34,892
GUEST SPEAKER 2: It must be very
hard, to not have anyone
1186
01:00:34,892 --> 01:00:35,750
to talk to or feel
comfortable with.
1187
01:00:35,750 --> 01:00:37,160
ROLE PLAYING PATIENT: That's
why I want to talk
1188
01:00:37,160 --> 01:00:38,790
[UNINTELLIGIBLE] with John.
1189
01:00:38,790 --> 01:00:40,500
GUEST SPEAKER 2: Well,
I'm sorry you're
1190
01:00:40,500 --> 01:00:43,104
struggling so much.
1191
01:00:43,104 --> 01:00:45,990
And I know we haven't
met before.
1192
01:00:45,990 --> 01:00:48,395
But I'm here and trying
to be helpful to you.
1193
01:00:48,395 --> 01:00:50,836
ROLE PLAYING PATIENT: You want
to kill me, don't you?
1194
01:00:50,836 --> 01:00:53,476
GUEST SPEAKER 2: No, I don't
think I want to.
1195
01:00:53,476 --> 01:00:56,392
1196
01:00:56,392 --> 01:01:03,682
ROLE PLAYING PATIENT:
[GRUNTING]
1197
01:01:03,682 --> 01:01:06,438
GUEST SPEAKER 2: So we have
a number of options.
1198
01:01:06,438 --> 01:01:09,784
And I think you look angry.
1199
01:01:09,784 --> 01:01:11,218
And you're scaring people
and you're scaring me.
1200
01:01:11,218 --> 01:01:12,005
ROLE PLAYING PATIENT: Fine.
1201
01:01:12,005 --> 01:01:15,066
GUEST SPEAKER 2: You're
scaring me.
1202
01:01:15,066 --> 01:01:16,050
ROLE PLAYING PATIENT:
[UNINTELLIGIBLE]
1203
01:01:16,050 --> 01:01:18,018
You're just laughing
behind me.
1204
01:01:18,018 --> 01:01:19,002
You're not scared.
1205
01:01:19,002 --> 01:01:19,494
You're just laughing.
1206
01:01:19,494 --> 01:01:21,860
GUEST SPEAKER 2: No, I think
you're a big, strong guy.
1207
01:01:21,860 --> 01:01:25,325
And when you get angry and
upset, you get to be
1208
01:01:25,325 --> 01:01:25,820
intimidating.
1209
01:01:25,820 --> 01:01:26,810
And there are other--
1210
01:01:26,810 --> 01:01:29,285
ROLE PLAYING PATIENT: Is that
why you're going to poison me?
1211
01:01:29,285 --> 01:01:29,780
Scared of me?
1212
01:01:29,780 --> 01:01:30,770
GUEST SPEAKER 2: No.
1213
01:01:30,770 --> 01:01:33,159
Well, I'm not trying
to hurt you.
1214
01:01:33,159 --> 01:01:36,652
But we need to come up
with a solution.
1215
01:01:36,652 --> 01:01:38,648
Because you could get hurt and
other people could get hurt.
1216
01:01:38,648 --> 01:01:41,642
So we need to do something
about that.
1217
01:01:41,642 --> 01:01:43,638
ROLE PLAYING PATIENT: I would
be better off dead.
1218
01:01:43,638 --> 01:01:45,135
Everyone wants me dead.
1219
01:01:45,135 --> 01:01:46,133
GUEST SPEAKER 2: Well.
1220
01:01:46,133 --> 01:01:50,624
I understand you're quite
distraught today.
1221
01:01:50,624 --> 01:01:53,119
And I want to help you.
1222
01:01:53,119 --> 01:01:55,614
I may not be able
to, right away.
1223
01:01:55,614 --> 01:02:03,099
1224
01:02:03,099 --> 01:02:09,586
I'm going to try to get the
nurse that you want.
1225
01:02:09,586 --> 01:02:12,580
But what if I do not get him?
1226
01:02:12,580 --> 01:02:16,073
What's the next best thing?
1227
01:02:16,073 --> 01:02:17,323
ROLE PLAYING PATIENT:
[INAUDIBLE]
1228
01:02:17,323 --> 01:02:20,065
1229
01:02:20,065 --> 01:02:21,562
I don't know.
1230
01:02:21,562 --> 01:02:26,053
GUEST SPEAKER 2: Would it help
to contact your family?
1231
01:02:26,053 --> 01:02:27,550
ROLE PLAYING PATIENT:
Maybe mom.
1232
01:02:27,550 --> 01:02:28,049
I want my mom.
1233
01:02:28,049 --> 01:02:29,047
GUEST SPEAKER 2: OK.
1234
01:02:29,047 --> 01:02:32,041
I can try to reach out to her.
1235
01:02:32,041 --> 01:02:35,855
And do you think that if you
change the medications maybe
1236
01:02:35,855 --> 01:02:39,110
you can try a combination
that could help?
1237
01:02:39,110 --> 01:02:41,013
ROLE PLAYING PATIENT: As long
as it's not poison.
1238
01:02:41,013 --> 01:02:41,780
GUEST SPEAKER 2: OK.
1239
01:02:41,780 --> 01:02:43,466
I hear you.
1240
01:02:43,466 --> 01:02:46,424
You don't like the medication.
1241
01:02:46,424 --> 01:02:48,396
You think that it's
hurting you.
1242
01:02:48,396 --> 01:02:50,368
But it's helped in the past.
1243
01:02:50,368 --> 01:02:54,805
And maybe a different
combination would be better.
1244
01:02:54,805 --> 01:02:55,298
Hmm?
1245
01:02:55,298 --> 01:02:56,284
ROLE PLAYING PATIENT: Maybe.
1246
01:02:56,284 --> 01:02:57,534
GUEST SPEAKER 2: Maybe?
1247
01:02:57,534 --> 01:03:02,228
1248
01:03:02,228 --> 01:03:03,674
Well, thank you.
1249
01:03:03,674 --> 01:03:05,210
We can go on like this.
1250
01:03:05,210 --> 01:03:13,130
[LAUGHTER, APPLAUSE]
1251
01:03:13,130 --> 01:03:14,380
[INTERPOSING VOICES]
1252
01:03:14,380 --> 01:03:27,968
1253
01:03:27,968 --> 01:03:32,570
AUDIENCE: I have a question
concerning about the
1254
01:03:32,570 --> 01:03:37,288
disruption of narrative model
of why violence occurs.
1255
01:03:37,288 --> 01:03:41,320
Is that pretty much accepted
as the way--
1256
01:03:41,320 --> 01:03:44,320
GUEST SPEAKER 2: I just
made it up for this.
1257
01:03:44,320 --> 01:03:44,820
[LAUGHTER]
1258
01:03:44,820 --> 01:03:47,300
AUDIENCE: I was just wondering
if there were competing,
1259
01:03:47,300 --> 01:03:50,811
different theories, it might
be useful for people to
1260
01:03:50,811 --> 01:03:52,759
understand more than one model,
or is that [INAUDIBLE].
1261
01:03:52,759 --> 01:03:58,190
GUEST SPEAKER 2: The narrative
perspective is, if you want, a
1262
01:03:58,190 --> 01:04:00,000
cry from the past.
1263
01:04:00,000 --> 01:04:03,731
I think the last 20 years,
in science and certainly
1264
01:04:03,731 --> 01:04:07,550
medicine, have been dominated
by hard evidence.
1265
01:04:07,550 --> 01:04:12,316
Actually, the evidence-based
medicine has been taking over
1266
01:04:12,316 --> 01:04:16,060
the entire world, as the
ultimate standard.
1267
01:04:16,060 --> 01:04:22,430
So there are lists of the
strength of the evidence, and
1268
01:04:22,430 --> 01:04:28,286
randomized controlled designs
are the best, and clinical
1269
01:04:28,286 --> 01:04:31,060
impression anecdotes
are the worst.
1270
01:04:31,060 --> 01:04:38,090
So on this map, the narrative
or a person-like story about
1271
01:04:38,090 --> 01:04:44,780
the patient may not be if you
want the accepted model today.
1272
01:04:44,780 --> 01:04:49,538
But I think in dealing with
individual cases, I feel that
1273
01:04:49,538 --> 01:04:51,017
makes a lot of sense.
1274
01:04:51,017 --> 01:04:52,870
When you have to deal with
somebody who is very
1275
01:04:52,870 --> 01:04:57,560
distraught, if I tell him that
the best available evidence
1276
01:04:57,560 --> 01:05:01,954
was published two years ago and
showed that, you know, 20
1277
01:05:01,954 --> 01:05:05,930
milligrams of Abilify would work
best for psychosis, I'm
1278
01:05:05,930 --> 01:05:08,663
not so sure that you
would fuel the
1279
01:05:08,663 --> 01:05:10,403
warmth and the empathy.
1280
01:05:10,403 --> 01:05:12,910
1281
01:05:12,910 --> 01:05:15,180
But the reality, it
could be that that
1282
01:05:15,180 --> 01:05:17,040
evidence is is right.
1283
01:05:17,040 --> 01:05:18,260
He's psychotic.
1284
01:05:18,260 --> 01:05:20,130
And he tried to a variety
of medications.
1285
01:05:20,130 --> 01:05:23,080
Some of them made him fat and
pushed his triglycerides up
1286
01:05:23,080 --> 01:05:25,365
and raised his blood pressure.
1287
01:05:25,365 --> 01:05:30,310
If I switch him to Abilify in
two months, he'll get better.
1288
01:05:30,310 --> 01:05:37,600
But dealing with the immediate
issue, I think it's just, it's
1289
01:05:37,600 --> 01:05:38,572
something else.
1290
01:05:38,572 --> 01:05:41,609
And that knowledge about
medication, while helpful in
1291
01:05:41,609 --> 01:05:42,470
the long run, will not
make it very good.
1292
01:05:42,470 --> 01:05:46,500
So this is why I came up with
if you want, for the purpose
1293
01:05:46,500 --> 01:05:53,210
of this meeting, with a way of
creating a metaphor that could
1294
01:05:53,210 --> 01:05:58,130
sustain my verbal and nonverbal
de-escalation.
1295
01:05:58,130 --> 01:06:03,720
I'm trying to create some sense,
some coherence, some
1296
01:06:03,720 --> 01:06:07,046
meaning, some meaning
to that interaction.
1297
01:06:07,046 --> 01:06:10,822
And in doing that, I'm empathic
and I'm trying to
1298
01:06:10,822 --> 01:06:14,430
channel the energies
in a way that it's
1299
01:06:14,430 --> 01:06:15,860
almost like a beginning.
1300
01:06:15,860 --> 01:06:16,370
He's distraught.
1301
01:06:16,370 --> 01:06:17,450
He's ready to give up.
1302
01:06:17,450 --> 01:06:20,715
He's ready to shut himself
away from the world.
1303
01:06:20,715 --> 01:06:23,800
I'm trying to reach out to
him, without becoming his
1304
01:06:23,800 --> 01:06:27,300
friend, without becoming
his brother or father.
1305
01:06:27,300 --> 01:06:30,556
And I think in a sense
I'm restoring the
1306
01:06:30,556 --> 01:06:32,230
meaning of his narrative.
1307
01:06:32,230 --> 01:06:35,462
Somebody cares, somebody
reaches out.
1308
01:06:35,462 --> 01:06:38,060
PROFESSOR: Because it seems like
a very interesting system
1309
01:06:38,060 --> 01:06:42,490
for people, for designers
to play with.
1310
01:06:42,490 --> 01:06:45,100
The idea of trying, even though
there is this historic
1311
01:06:45,100 --> 01:06:49,470
narrative, and you may not
know enough about the
1312
01:06:49,470 --> 01:06:51,596
narrative to be able
to act on it.
1313
01:06:51,596 --> 01:06:53,303
But you'd find out things
about it by
1314
01:06:53,303 --> 01:06:54,920
talking to the patient.
1315
01:06:54,920 --> 01:06:59,015
And what you're really trying
to do is make things fit
1316
01:06:59,015 --> 01:07:00,955
within that person's
narrative.
1317
01:07:00,955 --> 01:07:03,290
GUEST SPEAKER 2: You're filling
the blanks that were
1318
01:07:03,290 --> 01:07:05,450
kind of somewhat destroyed
by events.
1319
01:07:05,450 --> 01:07:09,300
And it could be a variety
of events.
1320
01:07:09,300 --> 01:07:11,190
And at times you have to
use your imagination.
1321
01:07:11,190 --> 01:07:12,410
It's almost like intuition.
1322
01:07:12,410 --> 01:07:15,450
I mean, I know the principles
from every case, but how I'm
1323
01:07:15,450 --> 01:07:20,414
going to do it, it's
not pre-programmed.
1324
01:07:20,414 --> 01:07:24,150
PROFESSOR: Seems like that's
also something that you could
1325
01:07:24,150 --> 01:07:26,700
then play with from a design
point of view.
1326
01:07:26,700 --> 01:07:30,550
This idea of disruptive
narrative, and then how do you
1327
01:07:30,550 --> 01:07:31,570
put it back.
1328
01:07:31,570 --> 01:07:36,210
Just like putting the pieces
back together [INAUDIBLE].
1329
01:07:36,210 --> 01:07:38,352
GUEST SPEAKER 2: That may be
the reason-- and that's
1330
01:07:38,352 --> 01:07:40,320
another speculation, I'm
just making this up--
1331
01:07:40,320 --> 01:07:44,200
why adventure games
are so powerful.
1332
01:07:44,200 --> 01:07:46,100
Because, in a sense, you're
finding a substitute narrative
1333
01:07:46,100 --> 01:07:50,622
that is much more controllable
than your own.
1334
01:07:50,622 --> 01:07:55,230
And for the time of the
game you're there.
1335
01:07:55,230 --> 01:07:59,500
It's almost like you're buying
a few minutes, 10 minutes, 20
1336
01:07:59,500 --> 01:08:01,500
minutes of a different
story line.
1337
01:08:01,500 --> 01:08:03,690
PROFESSOR: Actually, one of
our researchers here looks
1338
01:08:03,690 --> 01:08:05,212
specifically at adventure
games.
1339
01:08:05,212 --> 01:08:07,570
And her point of view is that
playing adventure games is
1340
01:08:07,570 --> 01:08:12,440
like being a performer who
hasn't been given the script.
1341
01:08:12,440 --> 01:08:15,080
You're still an actor in the
story, and you have to figure
1342
01:08:15,080 --> 01:08:17,454
out what that story is in
order to move it along.
1343
01:08:17,454 --> 01:08:23,190
1344
01:08:23,190 --> 01:08:25,819
There's one other thing that
I do want to bring up.
1345
01:08:25,819 --> 01:08:28,550
Obviously, I don't want any of
these games that you guys are
1346
01:08:28,550 --> 01:08:33,819
working on to be quizzes, to be
really fun quizzes, even.
1347
01:08:33,819 --> 01:08:36,219
[INAUDIBLE]
1348
01:08:36,219 --> 01:08:37,819
all this stuff is about.
1349
01:08:37,819 --> 01:08:40,097
I do want you guys to
be learning games.
1350
01:08:40,097 --> 01:08:43,061
And not just Trivial Pursuit,
Psychiatric Version.
1351
01:08:43,061 --> 01:08:47,020
1352
01:08:47,020 --> 01:08:48,809
That's kind of pointless.
1353
01:08:48,809 --> 01:08:51,600
We have had games in the past
in this class where people
1354
01:08:51,600 --> 01:08:55,526
basically pulled questions out
of a hat and had to answer
1355
01:08:55,526 --> 01:08:57,490
them, with various penalties.
1356
01:08:57,490 --> 01:08:59,904
Kind of fun, but that's
not what I've been
1357
01:08:59,904 --> 01:09:01,729
teaching you guys.
1358
01:09:01,729 --> 01:09:03,550
So try to think about systems.
1359
01:09:03,550 --> 01:09:07,532
Try to think about all these
things that they want their
1360
01:09:07,532 --> 01:09:09,390
trainees to learn.
1361
01:09:09,390 --> 01:09:12,892
Think about how they can engage
with the system, in
1362
01:09:12,892 --> 01:09:14,868
some small way, for
your project.
1363
01:09:14,868 --> 01:09:19,314
1364
01:09:19,314 --> 01:09:20,796
AUDIENCE: Can I ask
a question?
1365
01:09:20,796 --> 01:09:23,760
What are your thoughts, or what
are the field's thoughts
1366
01:09:23,760 --> 01:09:25,670
on lying to people, so
mitigate a situation.
1367
01:09:25,670 --> 01:09:28,485
1368
01:09:28,485 --> 01:09:36,120
GUEST SPEAKER 2: Well, I would
call lying a distortion, in a
1369
01:09:36,120 --> 01:09:39,745
very general way.
1370
01:09:39,745 --> 01:09:45,222
And when people lie, they
have to make a decision.
1371
01:09:45,222 --> 01:09:49,614
Often, people lie for a
variety of reasons.
1372
01:09:49,614 --> 01:09:54,006
What I always am surprised by is
the reason to make friends,
1373
01:09:54,006 --> 01:09:57,422
to get friendly, to resolve
a situation.
1374
01:09:57,422 --> 01:10:05,175
And I don't believe in lying
as a communication tool.
1375
01:10:05,175 --> 01:10:09,925
Given, it may make things
easier in the short run.
1376
01:10:09,925 --> 01:10:13,818
Certainly clinically
it's not helpful.
1377
01:10:13,818 --> 01:10:17,269
I was telling you about patients
with borderline
1378
01:10:17,269 --> 01:10:20,720
pathology that has this
affective and relational
1379
01:10:20,720 --> 01:10:24,690
instability that is basically
taking over their lives.
1380
01:10:24,690 --> 01:10:28,427
They are some of the most
accurate lie detectors that
1381
01:10:28,427 --> 01:10:29,160
you can imagine.
1382
01:10:29,160 --> 01:10:32,320
You cannot design something
more perfect than that.
1383
01:10:32,320 --> 01:10:34,750
Especially having been in the
system for a long time.
1384
01:10:34,750 --> 01:10:38,152
They can feel the lie even
before it comes up.
1385
01:10:38,152 --> 01:10:40,582
And if you're going that
path with them.
1386
01:10:40,582 --> 01:10:44,230
AUDIENCE: So this role play,
for example, if you told
1387
01:10:44,230 --> 01:10:46,070
Bobby, well, let
me go get John.
1388
01:10:46,070 --> 01:10:47,420
You wait here for a minute.
1389
01:10:47,420 --> 01:10:50,210
And then you know that John
is not working right now.
1390
01:10:50,210 --> 01:10:51,550
He's nowhere in the hospital.
1391
01:10:51,550 --> 01:10:54,430
But you just told him that to
safely get out, then you get
1392
01:10:54,430 --> 01:10:56,890
security to come back in
with you, and you can
1393
01:10:56,890 --> 01:10:57,445
subdue him or something.
1394
01:10:57,445 --> 01:10:59,666
GUEST SPEAKER 2: That's
a great example.
1395
01:10:59,666 --> 01:11:01,986
And that happens all the time.
1396
01:11:01,986 --> 01:11:05,420
Because often when you're in
this place, many of your
1397
01:11:05,420 --> 01:11:07,920
requests are unreasonable.
1398
01:11:07,920 --> 01:11:11,150
So you need to set
some limits.
1399
01:11:11,150 --> 01:11:13,752
And eventually you'll end
up setting some limits.
1400
01:11:13,752 --> 01:11:15,730
He could have continued to
escalate until attacking me,
1401
01:11:15,730 --> 01:11:18,352
breaking everything
in the room.
1402
01:11:18,352 --> 01:11:22,708
I usually tell them about how
they make others feel.
1403
01:11:22,708 --> 01:11:27,548
How unacceptable some of their
behaviors are, and what are
1404
01:11:27,548 --> 01:11:28,516
the consequences.
1405
01:11:28,516 --> 01:11:33,074
So I'm going to probably tell
you if this continues, I don't
1406
01:11:33,074 --> 01:11:36,278
have any other choice but to
call security and you may end
1407
01:11:36,278 --> 01:11:36,490
up in restraints.
1408
01:11:36,490 --> 01:11:38,442
And with a chemical medication,
it could be
1409
01:11:38,442 --> 01:11:40,900
injectable, you can
take it by mouth.
1410
01:11:40,900 --> 01:11:45,168
So I'm coming up front with how
the next few minutes, the
1411
01:11:45,168 --> 01:11:47,144
proximal future, looks like.
1412
01:11:47,144 --> 01:11:50,780
As opposed to kind of fudge it
and get on his friendly side,
1413
01:11:50,780 --> 01:11:54,918
and, oh I don't mean anything,
but the security will put you
1414
01:11:54,918 --> 01:11:56,072
in restraints.
1415
01:11:56,072 --> 01:12:01,050
So I don't want to buy him out
by just becoming his friend.
1416
01:12:01,050 --> 01:12:03,050
If that involves lying--
1417
01:12:03,050 --> 01:12:05,190
that's-- some people do it.
1418
01:12:05,190 --> 01:12:06,130
When you're in the
corner, you're--
1419
01:12:06,130 --> 01:12:08,325
OK, so what do I do now.
1420
01:12:08,325 --> 01:12:09,890
A little lie won't hurt.
1421
01:12:09,890 --> 01:12:11,095
And you do it.
1422
01:12:11,095 --> 01:12:12,292
Maybe it's just my--
1423
01:12:12,292 --> 01:12:14,020
GUEST SPEAKER 1: What you just
mentioned too, that sort of
1424
01:12:14,020 --> 01:12:15,974
like good cop, bad cop.
1425
01:12:15,974 --> 01:12:19,140
Well, I wish we could have more
of a conversation here,
1426
01:12:19,140 --> 01:12:21,110
but security needs to put
you in restraints.
1427
01:12:21,110 --> 01:12:22,290
Security's the bad guy.
1428
01:12:22,290 --> 01:12:24,610
When that's exactly
where you want the
1429
01:12:24,610 --> 01:12:25,801
patient to be anyways.
1430
01:12:25,801 --> 01:12:27,486
GUEST SPEAKER 2: I'm OK,
but you know Jim.
1431
01:12:27,486 --> 01:12:28,830
He doesn't tolerate it.
1432
01:12:28,830 --> 01:12:30,620
He's the director and
he's going to--
1433
01:12:30,620 --> 01:12:31,910
[LAUGHTER]
1434
01:12:31,910 --> 01:12:33,820
GUEST SPEAKER 2: Does that
answer your question?
1435
01:12:33,820 --> 01:12:34,380
AUDIENCE: Yeah.
1436
01:12:34,380 --> 01:12:35,020
Would you--
1437
01:12:35,020 --> 01:12:36,270
[INTERPOSING VOICES]
1438
01:12:36,270 --> 01:12:38,244
1439
01:12:38,244 --> 01:12:40,745
AUDIENCE: I guess my followup is
would you ever sneakily put
1440
01:12:40,745 --> 01:12:42,940
medicine in someone's food or do
something [UNINTELLIGIBLE].
1441
01:12:42,940 --> 01:12:48,716
GUEST SPEAKER 2: It's not only
a lawsuit waiting to happen,
1442
01:12:48,716 --> 01:12:54,080
of a major magnitude, but I
don't think it's right.
1443
01:12:54,080 --> 01:12:58,566
Even though probably reality
is that family members and
1444
01:12:58,566 --> 01:13:01,458
sometimes even providers in
nursing homes may do that.
1445
01:13:01,458 --> 01:13:04,006
But I think it's--
1446
01:13:04,006 --> 01:13:07,010
GUEST SPEAKER 1: You may need
to treat the person against
1447
01:13:07,010 --> 01:13:09,450
their will, which is often
meaning putting them into
1448
01:13:09,450 --> 01:13:11,640
physical restraints, which is
usually like leather kind of
1449
01:13:11,640 --> 01:13:14,800
things, kind of a straitjacket
thing, or maybe to a bed.
1450
01:13:14,800 --> 01:13:17,480
And maybe physically inject them
with something to really
1451
01:13:17,480 --> 01:13:18,420
sedate them.
1452
01:13:18,420 --> 01:13:20,174
But you should always be telling
them what you're going
1453
01:13:20,174 --> 01:13:20,990
to do, right.
1454
01:13:20,990 --> 01:13:23,230
And the reason why
you're doing it.
1455
01:13:23,230 --> 01:13:24,895
Even if they don't have any
choice in the matter.
1456
01:13:24,895 --> 01:13:27,780
GUEST SPEAKER 2: And if you feel
that the person is unable
1457
01:13:27,780 --> 01:13:35,490
to comprehend, then you may
need to work towards
1458
01:13:35,490 --> 01:13:36,700
appointing a guardian
who will take
1459
01:13:36,700 --> 01:13:39,240
decisions for that person.
1460
01:13:39,240 --> 01:13:41,810
And it's not necessarily that
the legal field has pushed
1461
01:13:41,810 --> 01:13:43,940
itself very hard in field.
1462
01:13:43,940 --> 01:13:46,390
But I think it's fair.
1463
01:13:46,390 --> 01:13:48,250
You meet the person where
that person is at,
1464
01:13:48,250 --> 01:13:49,550
and try to be helpful.
1465
01:13:49,550 --> 01:13:53,010
And I think, in my view, there
is no substitute for being
1466
01:13:53,010 --> 01:13:55,390
upfront and saying this is
what's going to happen.
1467
01:13:55,390 --> 01:13:58,490
He may not be my best friend,
but he knows exactly.
1468
01:13:58,490 --> 01:14:02,873
I'm telling the patients often
ahead what's going to happen.
1469
01:14:02,873 --> 01:14:05,010
In that sense, I'm giving
them choices.
1470
01:14:05,010 --> 01:14:07,279
So if I end up taking
them to court for
1471
01:14:07,279 --> 01:14:08,700
commitment, they know that.
1472
01:14:08,700 --> 01:14:13,220
And you would be surprised
how angry they are at the
1473
01:14:13,220 --> 01:14:15,386
beginning and how OK
they are later.
1474
01:14:15,386 --> 01:14:18,580
And how often they come up to
me and say, thank you, I was
1475
01:14:18,580 --> 01:14:23,480
in a very bad space and I didn't
want to, and I fought
1476
01:14:23,480 --> 01:14:24,950
you all the way but I think that
was the best solution.
1477
01:14:24,950 --> 01:14:28,380
I don't necessarily do that
to get that thanks.
1478
01:14:28,380 --> 01:14:30,340
I just do it as a principle.
1479
01:14:30,340 --> 01:14:31,820
Often it doesn't come.
1480
01:14:31,820 --> 01:14:33,200
It's not like people
are grateful.
1481
01:14:33,200 --> 01:14:35,880
Often they leave the hospital.
1482
01:14:35,880 --> 01:14:39,505
GUEST SPEAKER 1: Let me show a
little of this training, just
1483
01:14:39,505 --> 01:14:39,880
a few minutes.
1484
01:14:39,880 --> 01:14:44,580
This is a project I've been
working on a lot for NASA,
1485
01:14:44,580 --> 01:14:47,920
which is basically to develop a
mental health support system
1486
01:14:47,920 --> 01:14:49,410
for the long duration
space cruise.
1487
01:14:49,410 --> 01:14:51,730
And this is kind of a
whole other topic.
1488
01:14:51,730 --> 01:14:54,880
But just one piece of this was
teaching the astronauts how to
1489
01:14:54,880 --> 01:14:58,236
manage conflict, interpersonal
conflict more
1490
01:14:58,236 --> 01:15:00,515
effectively or safely.
1491
01:15:00,515 --> 01:15:03,370
1492
01:15:03,370 --> 01:15:05,810
Astronauts being a very
different population from what
1493
01:15:05,810 --> 01:15:07,762
we were talking about.
1494
01:15:07,762 --> 01:15:42,444
1495
01:15:42,444 --> 01:15:45,420
[VIDEO PLAYBACK]
1496
01:15:45,420 --> 01:15:49,636
--Welcome to the virtual space
station, where you can access
1497
01:15:49,636 --> 01:15:52,116
training and resources to help
deal with the stresses of long
1498
01:15:52,116 --> 01:15:53,356
duration space flights.
1499
01:15:53,356 --> 01:15:56,332
In the training simulator,
you'll interact with virtual
1500
01:15:56,332 --> 01:15:58,812
crew members to learn and
practice managing some of the
1501
01:15:58,812 --> 01:16:01,788
problems that might come up
on long duration missions.
1502
01:16:01,788 --> 01:16:05,508
The resources modules has more
advanced training that you can
1503
01:16:05,508 --> 01:16:08,020
do to learn about adapting to
the stresses of living in
1504
01:16:08,020 --> 01:16:11,055
isolation, plus interviews with
long duration flyers.
1505
01:16:11,055 --> 01:16:15,370
It also has a number of ebooks
and audio books on dealing
1506
01:16:15,370 --> 01:16:16,070
with stress.
1507
01:16:16,070 --> 01:16:18,860
Plus survival stories about
polar missions and other
1508
01:16:18,860 --> 01:16:20,020
adventures.
1509
01:16:20,020 --> 01:16:24,136
In the self-assessment module,
you'll find questionnaires--
1510
01:16:24,136 --> 01:16:24,588
[END VIDEO PLAYBACK]
1511
01:16:24,588 --> 01:16:27,760
GUEST SPEAKER 1: This is
basically the whole interface.
1512
01:16:27,760 --> 01:16:31,084
What I'll show you here
is our simulator.
1513
01:16:31,084 --> 01:16:31,512
[VIDEO PLAYBACK]
1514
01:16:31,512 --> 01:16:33,455
--This is the training
simulator.
1515
01:16:33,455 --> 01:16:36,030
Click on the topic you would
like to learn about.
1516
01:16:36,030 --> 01:16:40,350
Then the coach or mentor for
that topic will takeover and
1517
01:16:40,350 --> 01:16:41,310
guide you through.
1518
01:16:41,310 --> 01:16:41,790
--
1519
01:16:41,790 --> 01:16:42,750
This is the conflict
1520
01:16:42,750 --> 01:16:44,190
management part of the simulator.
1521
01:16:44,190 --> 01:16:48,245
We recommend that you do the
10 minute briefing first.
1522
01:16:48,245 --> 01:16:49,840
After you complete
each simulation--
1523
01:16:49,840 --> 01:16:51,090
[INTERPOSING VOICES]
1524
01:16:51,090 --> 01:16:55,050
1525
01:16:55,050 --> 01:16:57,425
Here's how these simulations
work.
1526
01:16:57,425 --> 01:17:00,730
You're flight engineer
one, or FE1.
1527
01:17:00,730 --> 01:17:04,440
Your crew mate, Chuck, is
flight engineer two.
1528
01:17:04,440 --> 01:17:08,030
We'll be giving you three
choices of what to say or do.
1529
01:17:08,030 --> 01:17:11,050
You can roll your mouse over
them to hear how they're said.
1530
01:17:11,050 --> 01:17:14,660
Even though some options are
more likely than others to
1531
01:17:14,660 --> 01:17:17,360
reduce the conflict, I recommend
that you try out
1532
01:17:17,360 --> 01:17:19,648
options you might not
choose in real life.
1533
01:17:19,648 --> 01:17:22,680
That's because all paths in
these simulations lead to
1534
01:17:22,680 --> 01:17:24,210
teaching points.
1535
01:17:24,210 --> 01:17:27,835
You can click the backup button
anytime if you want to
1536
01:17:27,835 --> 01:17:29,650
change your choice and go
down another pathway.
1537
01:17:29,650 --> 01:17:32,760
You can click on the fair
fighting manual at any time to
1538
01:17:32,760 --> 01:17:34,560
read some tips.
1539
01:17:34,560 --> 01:17:36,220
You'll also find this
manual in the
1540
01:17:36,220 --> 01:17:38,573
resource module's library.
1541
01:17:38,573 --> 01:17:41,860
Now as you go through the
simulation, I'll be right here
1542
01:17:41,860 --> 01:17:44,240
coaching you along the way.
1543
01:17:44,240 --> 01:17:45,040
OK.
1544
01:17:45,040 --> 01:17:47,193
Back to the simulation.
1545
01:17:47,193 --> 01:17:50,990
It's four months into your
mission, with five and a half
1546
01:17:50,990 --> 01:17:51,820
left to go.
1547
01:17:51,820 --> 01:17:54,790
So far, the mission's been
going pretty well.
1548
01:17:54,790 --> 01:17:58,750
But you're both tired, having
had to sleep shift last night.
1549
01:17:58,750 --> 01:18:03,205
1550
01:18:03,205 --> 01:18:03,700
--
1551
01:18:03,700 --> 01:18:06,530
Is your display getting
squirrelly?
1552
01:18:06,530 --> 01:18:08,580
Shoot, mine too.
1553
01:18:08,580 --> 01:18:11,108
Damn, I think the whole
system's down.
1554
01:18:11,108 --> 01:18:12,972
It was the wrong cable.
1555
01:18:12,972 --> 01:18:16,360
When I was installing
the recorder I
1556
01:18:16,360 --> 01:18:18,350
disconnected the A10 cable.
1557
01:18:18,350 --> 01:18:21,433
I fixed it right away but
I think it screwed
1558
01:18:21,433 --> 01:18:22,390
up the whole system.
1559
01:18:22,390 --> 01:18:25,260
Look, if ground calls, don't
tell them about the cable.
1560
01:18:25,260 --> 01:18:29,555
1561
01:18:29,555 --> 01:18:29,960
--
1562
01:18:29,960 --> 01:18:31,782
Ah, this is a tricky
situation.
1563
01:18:31,782 --> 01:18:35,149
You believe it's important to
tell the ground what happened.
1564
01:18:35,149 --> 01:18:38,690
At the same time, you don't want
Chuck to get in trouble.
1565
01:18:38,690 --> 01:18:41,630
What's your response?
1566
01:18:41,630 --> 01:18:42,030
--
1567
01:18:42,030 --> 01:18:44,110
They'll spend hours trying
to figure this out.
1568
01:18:44,110 --> 01:18:45,185
We got to tell them.
1569
01:18:45,185 --> 01:18:47,520
What's wrong with telling
the ground.
1570
01:18:47,520 --> 01:18:47,790
--
1571
01:18:47,790 --> 01:18:48,070
You're saying make a choice.
1572
01:18:48,070 --> 01:18:48,405
--
1573
01:18:48,405 --> 01:18:50,740
OK, but you're putting
me in a bad position.
1574
01:18:50,740 --> 01:18:51,240
--
1575
01:18:51,240 --> 01:18:51,740
I know.
1576
01:18:51,740 --> 01:18:53,740
But thanks you're
a real friend.
1577
01:18:53,740 --> 01:18:55,740
I owe you big time.
1578
01:18:55,740 --> 01:18:59,240
1579
01:18:59,240 --> 01:18:59,740
--
1580
01:18:59,740 --> 01:19:00,985
Houston, this is FE2.
1581
01:19:00,985 --> 01:19:02,235
Go ahead.
1582
01:19:02,235 --> 01:19:04,300
1583
01:19:04,300 --> 01:19:04,580
No.
1584
01:19:04,580 --> 01:19:04,860
Negative.
1585
01:19:04,860 --> 01:19:07,904
I have no idea.
1586
01:19:07,904 --> 01:19:08,790
Yeah I know.
1587
01:19:08,790 --> 01:19:12,351
I already got the
reboot started.
1588
01:19:12,351 --> 01:19:17,420
No, I guess it's too early to
say what the impact is.
1589
01:19:17,420 --> 01:19:17,905
Roger that.
1590
01:19:17,905 --> 01:19:20,060
I'll let you know if
it happens again.
1591
01:19:20,060 --> 01:19:21,310
FE2 out.
1592
01:19:21,310 --> 01:19:24,156
1593
01:19:24,156 --> 01:19:24,640
--
1594
01:19:24,640 --> 01:19:27,890
You're feeling very anxious
having just heard Chuck lie to
1595
01:19:27,890 --> 01:19:28,970
the ground.
1596
01:19:28,970 --> 01:19:33,152
You're worried that this might
backfire on you, if the ground
1597
01:19:33,152 --> 01:19:34,960
finds out that you knew
what happened.
1598
01:19:34,960 --> 01:19:37,090
This makes you very
angry at Chuck.
1599
01:19:37,090 --> 01:19:39,450
How would you like to respond?
1600
01:19:39,450 --> 01:19:39,930
[END VIDEO PLAYBACK]
1601
01:19:39,930 --> 01:19:42,440
GUEST SPEAKER 1: The reason I'm
showing you this is that
1602
01:19:42,440 --> 01:19:44,820
this is one approach that I've
taken to teaching how to
1603
01:19:44,820 --> 01:19:47,410
handle an interaction with
somebody through sort of a
1604
01:19:47,410 --> 01:19:47,880
simulation.
1605
01:19:47,880 --> 01:19:49,750
Now this is obviously
not a game.
1606
01:19:49,750 --> 01:19:50,170
There's no score.
1607
01:19:50,170 --> 01:19:51,220
There's no time limit.
1608
01:19:51,220 --> 01:19:54,060
It's more of an interactive
movie.
1609
01:19:54,060 --> 01:19:57,570
But with the teaching points
here, just like what Cesar's
1610
01:19:57,570 --> 01:20:00,870
given you is, we can give this
to an astronaut and they'll
1611
01:20:00,870 --> 01:20:04,050
read it in 5-10 minutes and say,
yup, got it, what's the
1612
01:20:04,050 --> 01:20:04,760
next thing.
1613
01:20:04,760 --> 01:20:06,820
That doesn't mean they actually
can use it, remember
1614
01:20:06,820 --> 01:20:09,420
it, absorbed it.
1615
01:20:09,420 --> 01:20:10,745
and I'm not saying that
this is the way they
1616
01:20:10,745 --> 01:20:11,600
should do your games.
1617
01:20:11,600 --> 01:20:17,395
But that this is one approach
that we've taken to try to get
1618
01:20:17,395 --> 01:20:20,730
them more involved with the
material in more of a
1619
01:20:20,730 --> 01:20:21,910
simulated way.
1620
01:20:21,910 --> 01:20:24,500
We can just do maybe one
or two more of this.
1621
01:20:24,500 --> 01:20:25,890
What would you like
to do here?
1622
01:20:25,890 --> 01:20:26,340
[VIDEO PLAYBACK]
1623
01:20:26,340 --> 01:20:26,750
--
1624
01:20:26,750 --> 01:20:29,130
Chuck, we need to
talk about this.
1625
01:20:29,130 --> 01:20:29,610
--
1626
01:20:29,610 --> 01:20:31,540
What is there to talk about?
1627
01:20:31,540 --> 01:20:33,840
Ground doesn't need to
know every single
1628
01:20:33,840 --> 01:20:35,184
little detail, alright?
1629
01:20:35,184 --> 01:20:38,285
Plus if we do tell them, next
thing you know we're going to
1630
01:20:38,285 --> 01:20:38,530
be all over the news.
1631
01:20:38,530 --> 01:20:38,970
--
1632
01:20:38,970 --> 01:20:40,360
This was a good choice.
1633
01:20:40,360 --> 01:20:44,135
Even though Chuck seems
exasperated, you know what's
1634
01:20:44,135 --> 01:20:45,290
going on in his mind.
1635
01:20:45,290 --> 01:20:47,970
Understanding what each other is
thinking goes a long way to
1636
01:20:47,970 --> 01:20:49,383
solving conflict.
1637
01:20:49,383 --> 01:20:52,855
Chuck is concerned about the
ruckus this might cause about
1638
01:20:52,855 --> 01:20:54,480
negative media attention.
1639
01:20:54,480 --> 01:20:56,320
But now you have something
to work with.
1640
01:20:56,320 --> 01:20:58,316
What's your next move?
1641
01:20:58,316 --> 01:21:02,308
1642
01:21:02,308 --> 01:21:02,810
--
1643
01:21:02,810 --> 01:21:03,590
I know you--
1644
01:21:03,590 --> 01:21:05,780
you've been doing excellent
work so far.
1645
01:21:05,780 --> 01:21:07,753
I can see you're really
scared of them.
1646
01:21:07,753 --> 01:21:11,134
1647
01:21:11,134 --> 01:21:15,108
I know you don't want to draw
a lot of attention.
1648
01:21:15,108 --> 01:21:16,599
What'll you think will happen
if they figure it out?
1649
01:21:16,599 --> 01:21:17,096
--
1650
01:21:17,096 --> 01:21:17,593
OK.
1651
01:21:17,593 --> 01:21:19,084
You got a point.
1652
01:21:19,084 --> 01:21:19,581
I'll get fried.
1653
01:21:19,581 --> 01:21:24,205
Especially if it looked like I
was trying to cover it up.
1654
01:21:24,205 --> 01:21:27,790
You know, this really
is a team issue.
1655
01:21:27,790 --> 01:21:30,961
1656
01:21:30,961 --> 01:21:31,420
--
1657
01:21:31,420 --> 01:21:34,670
On one hand, you seemed to get
Chuck to come around to your
1658
01:21:34,670 --> 01:21:35,500
perspective.
1659
01:21:35,500 --> 01:21:38,560
But the ground really needs
to know what happened.
1660
01:21:38,560 --> 01:21:40,940
On the other hand, he's asking
you to share the
1661
01:21:40,940 --> 01:21:44,350
responsibility, even though it
really wasn't your fault.
1662
01:21:44,350 --> 01:21:45,810
You have mixed feelings.
1663
01:21:45,810 --> 01:21:48,810
You don't want to be blamed for
a mistake you didn't make.
1664
01:21:48,810 --> 01:21:51,360
But you're concerned about
keeping a good relationship
1665
01:21:51,360 --> 01:21:52,225
with Chuck.
1666
01:21:52,225 --> 01:21:53,525
How are you going to respond?
1667
01:21:53,525 --> 01:21:56,106
1668
01:21:56,106 --> 01:21:56,490
--
1669
01:21:56,490 --> 01:21:57,360
I'm sorry, Chuck.
1670
01:21:57,360 --> 01:22:00,900
But this was your mistake.
1671
01:22:00,900 --> 01:22:02,150
[INTERPOSING VOICES]
1672
01:22:02,150 --> 01:22:16,265
1673
01:22:16,265 --> 01:22:19,758
[LAUGHTER]
1674
01:22:19,758 --> 01:22:20,260
--
1675
01:22:20,260 --> 01:22:21,430
Houston, this is FE2.
1676
01:22:21,430 --> 01:22:21,925
--
1677
01:22:21,925 --> 01:22:22,915
Go ahead, FE2.
1678
01:22:22,915 --> 01:22:23,410
--
1679
01:22:23,410 --> 01:22:25,760
Houston, I think we
found the problem.
1680
01:22:25,760 --> 01:22:28,360
The instructions you sent up
for the recorder had some
1681
01:22:28,360 --> 01:22:30,020
serious problems.
1682
01:22:30,020 --> 01:22:33,125
When you follow the recorder
connect procedure, you can end
1683
01:22:33,125 --> 01:22:35,105
up disconnecting A10.
1684
01:22:35,105 --> 01:22:37,454
It may need to be validated.
1685
01:22:37,454 --> 01:22:37,941
--
1686
01:22:37,941 --> 01:22:38,915
Copy that, FE2.
1687
01:22:38,915 --> 01:22:40,863
The procedures team ran through
this in the mock-up,
1688
01:22:40,863 --> 01:22:43,298
but they can give
it another look.
1689
01:22:43,298 --> 01:22:43,785
--
1690
01:22:43,785 --> 01:22:49,060
In any organization [LAUGHTER]
1691
01:22:49,060 --> 01:22:51,700
Sometimes this can help to
create a bond within the
1692
01:22:51,700 --> 01:22:54,502
workgroup, because everybody
has a common enemy.
1693
01:22:54,502 --> 01:22:58,041
But, even though scapegoating
the ground may keep the crew
1694
01:22:58,041 --> 01:23:03,288
unified for a while,
1695
01:23:03,288 --> 01:23:03,764
[END VIDEO PLAYBACK]
1696
01:23:03,764 --> 01:23:04,520
GUEST SPEAKER 1: OK.
1697
01:23:04,520 --> 01:23:07,825
You kind of get the idea.
1698
01:23:07,825 --> 01:23:10,240
We'd like to be available by
email, in case you guys have
1699
01:23:10,240 --> 01:23:11,590
any questions.
1700
01:23:11,590 --> 01:23:15,500
PROFESSOR: I'll sent out some
tech information to the class
1701
01:23:15,500 --> 01:23:18,930
list and we're probably going to
spend the rest of this week
1702
01:23:18,930 --> 01:23:20,110
being around all of you so
we're not quite sure yet
1703
01:23:20,110 --> 01:23:21,360
exactly what we're
going to do yet.
1704
01:23:21,360 --> 01:23:24,745
1705
01:23:24,745 --> 01:23:25,995
Hopefully
[UNINTELLIGIBLE PHRASE].
1706
01:23:25,995 --> 01:23:29,850
1707
01:23:29,850 --> 01:23:32,580
I just have a couple more
[UNINTELLIGIBLE] things to do.
1708
01:23:32,580 --> 01:23:35,610
I wanted to thank you
guys first of all.
1709
01:23:35,610 --> 01:23:40,450
[APPLAUSE]
1710
01:23:40,450 --> 01:23:42,430
So let's see.
1711
01:23:42,430 --> 01:23:45,290
On next Wednesday, which is
the Wednesday right before
1712
01:23:45,290 --> 01:23:49,040
Thanksgiving, I think a couple
of folks are probably going to
1713
01:23:49,040 --> 01:23:50,290
be getting out--
1714
01:23:50,290 --> 01:23:54,020
1715
01:23:54,020 --> 01:23:57,970
because I've been hearing some
daffy stuff about what the TSA
1716
01:23:57,970 --> 01:24:00,095
might be doing, and what people
have been doing in
1717
01:24:00,095 --> 01:24:01,540
response to TSA [LAUGHTER].
1718
01:24:01,540 --> 01:24:04,420
1719
01:24:04,420 --> 01:24:07,250
Getting to the airport early,
if you are flying out, might
1720
01:24:07,250 --> 01:24:08,890
be a good idea.
1721
01:24:08,890 --> 01:24:12,120
Because if everybody decides
to refuse the bag scanner
1722
01:24:12,120 --> 01:24:15,430
scans and the body searches,
then we're talking about some
1723
01:24:15,430 --> 01:24:15,910
real delays.
1724
01:24:15,910 --> 01:24:17,170
Anyway.
1725
01:24:17,170 --> 01:24:21,090
So I think what I'm going to
do is [UNINTELLIGIBLE]
1726
01:24:21,090 --> 01:24:22,340
this class.
1727
01:24:22,340 --> 01:24:25,590
1728
01:24:25,590 --> 01:24:28,525
If there are teams who are
really wanting to do a live
1729
01:24:28,525 --> 01:24:31,550
action game, and they want to
get a head start on that, talk
1730
01:24:31,550 --> 01:24:32,560
to me directly.
1731
01:24:32,560 --> 01:24:37,150
And maybe what we can do is,
meet up with you as a team.
1732
01:24:37,150 --> 01:24:40,220
And try to get some
of ideas across.
1733
01:24:40,220 --> 01:24:43,450
Do a brainstorming with me.
1734
01:24:43,450 --> 01:24:46,610
I will also get into talking
about live action games the
1735
01:24:46,610 --> 01:24:47,907
following week.
1736
01:24:47,907 --> 01:24:50,769
I'll schedule one of the
classes for that.
1737
01:24:50,769 --> 01:24:54,130
So we're not going to
miss that topic.
1738
01:24:54,130 --> 01:24:56,880
I just worried that if we get
to it too late, and you are
1739
01:24:56,880 --> 01:24:58,470
making live action games, then
you don't have enough material
1740
01:24:58,470 --> 01:24:59,720
to work with.
1741
01:24:59,720 --> 01:25:06,590
1742
01:25:06,590 --> 01:25:10,520
Finally, about this assignment,
if the subject
1743
01:25:10,520 --> 01:25:16,436
matter is at all uncomfortable
for you to work with, and you
1744
01:25:16,436 --> 01:25:22,620
can't really find something in
this fairly large topic that
1745
01:25:22,620 --> 01:25:25,531
you will be comfortable working
with and you can't
1746
01:25:25,531 --> 01:25:28,720
find a team, talk
to me directly.
1747
01:25:28,720 --> 01:25:31,950
And we can work out some
other assignment.
1748
01:25:31,950 --> 01:25:34,270
I can't say that I have an
assignment in my back pocket
1749
01:25:34,270 --> 01:25:37,930
all ready to go, and more
likely than not, I'm
1750
01:25:37,930 --> 01:25:40,799
half-assing it too.
1751
01:25:40,799 --> 01:25:45,629
I would much prefer folks to
work on this problem that I
1752
01:25:45,629 --> 01:25:46,595
think is fascinating.
1753
01:25:46,595 --> 01:25:50,459
And a pretty big problem that
you can find some small
1754
01:25:50,459 --> 01:25:51,425
project that you're
comfortable with.
1755
01:25:51,425 --> 01:25:56,080
But if you are, I don't want to
make anyone uncomfortable
1756
01:25:56,080 --> 01:25:57,580
due to [INAUDIBLE].
1757
01:25:57,580 --> 01:25:58,830
So just talk to me.
1758
01:25:58,830 --> 01:26:04,956